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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i 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 Addressbane a ct, City Lot Size PM <br /> Owner's Nati� <br /> ^ , Address .� Phone <br /> ContractorAddress: License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES IDISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OFWELLPROBLEM AREA CONSTRUCTION SPECIFICATIONS <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 ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ___4pprox. Depth ❑ Eastern Surface Seal Installed by 93 <br /> Repair Work Done It Type of Pump _;_ H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material(top,50') <br /> Depth t ,a Filler Material (Below'501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑'- DESTRUCTION (71 INo septic system permitted if public sewer is <br /> available 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 1 <br /> PKG, TREATMENT PLT. ❑ Method of Disposal 1i <br /> Distance to+nearest: Well Foundation Property Line <br /> r <br /> LEACHING LINE ❑ No. & Length of lines Total length/size •_` <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property'tlne <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to, en arest: ' 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, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of Cal-ifornia."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 applicant must call fU2== <br /> rawing on rse side. <br /> Signed X �� Title: �oo_,� Date: 641 <br /> FOR DEPARTMENT USE ONLY <br /> e d y <br /> Application Accepted by Date Area AIT <br /> \ <br /> Pit or Grout Inspection by Date Final Inspection by Date !" <br /> Additional Comments: r Ltf <br /> ❑ Stk 466-6781 ❑ L i 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 96201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> Iff <br /> tEH132 [REv.1/551 <br /> I EH 1M28 <br />