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4 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> y 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED -3 <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. t ! <br /> .J Cit O of Size PM <br /> Job Address �j <br /> t /' f <br /> �Address / �� Phone <br /> Owner's N e mm t <br /> Address License No. Phone <br /> Contractor ' <br /> TYPE OF WELL/PUMP: NEW WELL Ll WELL REPLACEMENT ❑ DESTRUCTION <br /> —PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: TANK SEWER LINES DISPOSAL FLD. P <br /> FOUNDATI AGRICULTURE WELL OTHER PITS/SUMPS <br /> INTENDED USE TYPE OF.WELL PRO REA CONST SPECIFICATIONS <br /> - pia. of Well Casing <br /> ❑ Industrial '❑ Open Bottom O Manteca of Well Excavation . <br /> Type of Specifications <br /> ❑ Domestic I Private L1 Gravel Pack cY yp <br /> F1 Other •�I P Delta Depth of Grout Seal Type of Grout <br /> FI Public <br /> � <br /> . Depth I I Eastern Surface Seal Installed by <br /> I I Irrigation ppro <br /> H. State Work Done <br /> Repair Work Done Type of Pump <br /> Sealing Material /top 50.1 <br /> Well Wei 1 Diameter 9 <br /> epth - - Filler Material (Belo ' <br /> c system perm <br /> TYPE OF SEPTIC WOR NEW INSTALLATION l 1 REPAIR/ADDITION I DESTRUCT( N vat ble�wthin 200 fe t.)ed if public sewer is <br /> staliation will serve: Residence N{ - Commercial�. Other <br /> Num living units: Number of bedrooms <br /> Character of soi epth of 3 feet: a depth <br /> SEPTIC TANK ❑ f9 <br /> Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distanc"ej to nearest: Foundation Property Line <br /> LEACHING LINE Cl Length of lines Total length/size <br /> L FILTER BED ❑ Property Distance to nearest: ' Well Foundation Line <br /> I I <br /> PAGE PITS { I Depth I Size Number <br /> SUMPS L] Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <br /> ill be done in accordance with San Joaquin county ordinances• state laws, and <br /> Thereby certify that I 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." Contractors hiring or sub-contracting signature <br /> employ any person in such manner as io become subject to workman's compensation laws <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." I <br /> The applicant m all fpr all required inspections. Complete drawing on reverse side. f p C� <br /> Sign -� Title: Date: Q JGj <br /> FOR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by n <br /> Pit or Grout Inspectio y Date Final Inspection by Data JS <br /> Additional Comments: <br /> LlStk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 L1Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95.201 `` <br /> FEE AMOUNT DUE AMOUNT REMITTED CASK RECEIVED BY DATE PERMIT"NO. <br /> V' <br /> I INFO 2 {�7v� 00,0�N_ ��n J�_7 <br /> i +.EH13-24iREV.iiK51 315 ' 3 (r <br /> EH 14-26 <br />