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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON 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 City of Size PM <br /> A�oOwner's Name Z, Address Phone <br /> Contractor Address f d- 0 PSL kU''fd icense No. <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 USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (n <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public I] Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation _---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> k - <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction �❑ Well Diameter ° Sealing Material (top 501 _ D <br /> Depth Filler MaterialBlow 50') <br /> TYPE OF SEPTIC WORK: -NEW INSTALLATION ❑ REPAIR/ADDIT102N DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: ResidenCC mo mercial ..Other f t <br /> Number of living units: ������Nu��mmber of bedrooms _� S <br /> Character of soil to a depth of 3 feet:" Water table depth <br /> SEPTIC TANK ❑ Type/Mfg ; Capacity No. Compartments'- <br /> PKG. <br /> ompartments -PKG. TREATMENT PLT. ❑i° Method of Disposal <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 ' 15 jO Foundation r Property;Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property'Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be s ne in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. i <br /> y Home owner or licensed agent's signature certifies the following: "I certify that In the performance of the worm for which this permit is issued, I shall not <br /> i 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 applic t must c for all r ire i ctions. omplete drawing on reverse side. <br /> Signed X Title: /r Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by �- Date Area <br /> Pit or Grout Inspection y DateFinal Inspection by Date <br /> Additional-Comments: �3 <br /> ❑ Stk 466-6781 b ❑ Lodi 369-3921 ❑ Manteca 823-7104 ❑ Tracy 8366-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMO�UNT DUE AMOUNT REMITTED CK 4 CASH RECEIVED BY DATE PERMIT'NO. f.f <br /> + EH t3-24(REV.I/a 5) U/A <br /> ` " —uc, <br /> L f <br /> EH 14-28 6_1_e7p <br />