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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCACHEALTH DISTRICT <br /> 1601 E. HAZE 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 <br /> made permit to construct and/or install the work herein described. This application is <br /> Local Health District.compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Job Address .fl } <br /> City Lot Size PM <br /> Owner's Name by 0 ~`-. ;/� <br /> Address �� [ �� 3 V_ _ phone <br /> Contractor., GM f�.Address a `� <br /> License No. .3�� Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUC710N ❑ <br /> PUMP INSTALLATION <br /> DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR [D OTHER F-1I <br /> SEWER LINES DISPOSAL FLD. PROP. LINE X <br /> FOUNDATION AGRICULTURE WELL <br /> INTENDED USE OTHER WELL PITS/SUMPS <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> omestic/Private LJ Gravel Pack Fl Tracy T Dia. of Well Casing <br /> Public YPe of Casing Specifications <br /> ❑ Other ❑ Delta Depth of Grout Seal �. <br /> 7 Irrigation __A Type of Grout \ <br /> pprox. Dopth ElEastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of pump H.c_�� H.P. <br /> State Work Done <br /> Well Destruction El Well Diameter / . <br /> Sealing Material (top 501 <br /> Depth Filler Material (Below 50') I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> Installation will serve: Residence_ Commercial— Other available within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANKLJ Water table depth <br /> Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED E) Distance to nearest: Well Foundation Total length/size <br /> Property Line <br /> SEEPAGE PITS L7 Depth Size <br /> Number r <br /> SUMPS ❑ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ Property Line <br /> I 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." Contractors 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 applican c 'for allrpqui ed inspections. Complete drawing on r verse side. <br /> Signed // <br /> Date: <br /> Title: —� i� <br /> f <br /> FOR DEPARTMENT USE ONLY Application Accepted by Date <br /> Area <br /> Pit or Grout Inspection by Date Final inspection by <br /> Dat <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 JeTracy 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 AMOUNT DUE AMOUNT REMITTED CK# <br /> INFO CASH RECEIVED BY DATE <br /> ' i <br /> + EH 13-241REV.1/651 ZIIT'NO.EH 14-26 "J `� <br />