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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6181 <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 /> f Local Health District. <br /> i . City Lot Size PM <br /> Job Address TA <br /> ' Owner's Name. <br /> Address Phone <br /> I' <br /> Contractor's llama <br /> / License No ` Phone <br /> TYPE OF WELL/PUMP: NEW WELL 17f� WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> F PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK � .��� PITS/SUMPS <br /> k <br /> FOUNDATION AGRICULTURE WELL OTHER WELL— <br /> ! i� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation <br /> Specifications <br /> Type of Casing �� • <br /> l esticl Private [3Q.Qralel Pack �� / <br /> ❑ Other Delta Depth of.Grout Seal Type of Gr ut . l` <br /> F <br /> El Public • Q <br /> ❑ Irrigationpprox. Depth ❑ Eastern Surface Seal Installed by <br /> State Work Done <br /> Repair Work Done ❑ Type of Pump H.P. <br /> j Well Destruction ❑ Well Diameter Sealing Material (top 501 C <br /> I Depth Filler Material (Below 501 <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No seavailabptic within system rented if7sewer <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 1 <br /> PKG. TREATMENT PLT. <br /> El <br /> of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE I'] No. & Length of lines Total length/size <br /> '1 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number 7 <br /> i <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line s <br /> DISPOSAL PONDS ❑ <br /> Ill be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that 1 have prepared this application and that the work w <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 /> of California." <br /> employ any person in such manner as to become subject to workman's compensation laws 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 nt ust call for all require pectipns. Co, lets drawin ori re rse ide. <br /> Title: Date: a <br /> .Signed , <br /> R DEPART_ T USE ONLY <br /> �y <br /> Application Accepted by Date Area D <br /> Pit r Grout nspection by _ <br /> Date f1 p Final Inspection by Date a <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 AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'IVO. <br /> 1NF0 CASH <br /> EH-324 TREY.10!831 1 LA3• `� , � Cir~ �y1 c'11/19-4 <br /> EH 1428 _ - <br />