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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone 1209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made,to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. THs application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. } <br /> r <br /> Job Address / SCi Lot Size PM <br /> Owner's Name ZAddress Phone <br /> Contractor's Name 4z, <br /> License No. In Phone d <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USETlfl?E OF WELL-_PROBLEM-AREA-:CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open,Bottom LI-Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [I Domestic/Private ❑ Gra'e&Pack ❑ Tracy Type of Casing Specifications <br /> 0 Public ❑ Othe �„ T ❑ Delta Depth of Grout Seal- _. Type of Grout <br /> ❑ Irrigation �pprox. Depth E] Eastern is '`Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well.Diameter " ,Sealing.Material (top 501 <br /> k A <br /> Depth l � Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ 'TREPAIR/ADDITIONDESTRUCTION 11' (No septic system permitted if public sewer is <br /> ,available within 200 feet.) r <br /> Installation will serve: Residence .Commercial 'Other <br /> Number of living units: Number of bedroo s p ! <br /> I <br /> Character of soil to a depth of 3 fee : ' Watev table depth /D <br /> (� <br /> I SEPTIC TANK ❑ Type/Mfg -.—Capacity No. Compartments \ <br /> r <br /> PKG. TREATMENT PLT. ❑ , .., •Method of Disposal ' <br /> Distance to nearest: Well Foundation 'Property Line <br /> LEACHING LINE No. & Length of line �t"j,"!'7 Total length/size d <br /> FILTER BED ❑, Distance to nearest:' -WeII"""" --�TFbundaiioh"' "" Property Line <br /> SEEPAGE PITS Depth r]i� size 3-7 let -_ Number <br /> t <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> { rules and regulations of the San_Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for I req=in ' ns. Complete drawing on reverse side. <br /> Signed X Title: Date: Q s <br /> FOR DEPARTMENT USE ONLY <br /> k� S V� <br /> ( Application Accepted by Date Area <br /> [' Pit or Grout Inspection by Date Final Inspection by Date <br /> I: Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi-389-3621 ❑ Manteca 823-71 E ❑ Tracy f835-6385 __ rJc{ <br /> v}'� <br /> Applicant- Return all copies to: Environmental Health Permit/Svices 11 fi <br /> er60 . Hazelton Ave., P.O. Box 2009, Stk., CA 95201 b^ S <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. <br /> INFOCASH <br /> d �/J r <br /> `. + EH 13-24 MEV.101831 L4 5`9 10 <br /> �,.` EH 1428 . <br />