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APPLICATION FOR PERMIT _ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 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. This 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 /> Job Address _cJ City Lot Size PM <br /> Owner's Nam ' AG Address f^ if Phone 7 <br /> f <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL C1 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/SUMP <br /> INTENDED USE TY ELL PROBLEM AREA CONSTRUCTION SPECIFICAT <br /> ❑ Industrial ❑ Open Bottom Dia. of atlon Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy f Casing Specifications I <br /> ❑ Public ❑ Other elta Depth of Gro I Type of Grout <br /> ❑ Irrigation �4pp epth ❑ Eastern Surface Seal Installed by <br /> Repair Work bone ❑ of Pump H.P. State Work <br /> IN <br /> Well Destruction Well Diameter Sealing Material [tap 50'} <br /> Depth Filler Material lBelow 50'} I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTI(N (N eptic system permitted if public sewer is <br /> ailable within 200 feet.} <br /> Installation will serve: Residence_. Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT_ ❑ Method of Disposal 1 <br /> Distance to nearest: Well Foundation Property Line (� <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The appli st c II for all regyi a inspe tions. plete drawing on reverse side. <br /> Signed : Y ` Title: Date: <br /> FOR DE RTMENT U ONLY <br /> Application Accepted by Date <br /> Pit or Grout Inspection by Date final Inspection by <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE t � <br /> INFO �AjM�OUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIYNO. <br /> + EH1&241REV.iinsl l�L�� �C` Q� ��� ����� �,,,�—� <br /> EH 14-2a C..J� �3 <br />