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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT pAYMF.%T <br /> 1601 E. HAZELTON AVE., STOCKTON, CA REG�YV E� <br /> I Telephone {209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE'ISSUED AUG 27 19a7 <br /> (Complete in Triplicate) NTAL HEALT4� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work n is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and R� San Joaquin <br /> Local Health District. <br /> Job Address � City Lot Size PM <br /> r <br /> '-Owner's Name _Address - s, <br /> •Phone <br /> 11.2 <br /> Contractor Address License No. Phon f <br /> TYPE OF WELL/PUMP: 41 NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ( - <br /> PUMP INSTALLATIONX7 SYSTEM REPAIR ❑ OTHER ❑ V <br /> 4 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> IL Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br />' Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> I Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Imal_allation will serve: Residence_ Commercial_ Other <br /> Number units: Number of bedrooms <br /> Character of soil to a 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ - Method of Disposal <br /> Distance to nearest:. Well undation Property Line <br /> LEACHING LINE ❑ No. & Length of lines th/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Prope e <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 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'scompensation 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 applic must cag4w_all required inspections. Complete drawing on reverse side. <br /> Signed - Title: Date: V—'A S� <br /> FOR DEPARTME T USE ONLY <br /> Application Accepted by Date a �2- 7 -7 Area <br /> Pit or Grout Inspection by Date Final Inspection by Date 92 <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 /> i <br /> FEE AMOUNT DUE AMOUNT REMITTEp K <br /> INFO RECEIVED BY DATE PERMIT NO. <br /> EH 13-241REV.7/551 <br /> EH 1428 <br />