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APPLICATION FOR PERMIT <br /> r i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I <br /> j 1601 E. HAZEITON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> -PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is herebymadeto 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 th.Son Joaquin Cou.tyO Ordinance No.549 f sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> wi <br /> Local Health District.. <br /> r ,rr s City Lot Size PM <br /> Job Address <br /> a - <br /> ` Owner's NameAddress _ Phone <br /> ,., . <br /> Contractor, �� Address ` <br /> _ ._ __ 9 _ License. �_ Nop-7 Phone <br /> TYPE OF WELLIPUMP: NEW WELL ❑- WELL REPLACEMENT LJ -DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE'TO NEAREST: SEPTIC.TANK SEWER LINES DISPOSAL FI-15.— PROP.�LINE <br /> FOUNDATIONF AGRICULTURE L OTHER WELL. PITSlSUMPS <br /> INTENDED USE TYPE OF.WELL PROBLEM AR CONSTRUCTION SPECIFICATIONS, <br /> } ❑ Industria{ ❑ Open Bottom ❑ Mant Dia, of Well Excavation. I Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ cY Type of Casing I Specifications <br /> ❑ Public ❑ Other !� Delta Depth of Grout Seal s Type of Grout` <br /> 7-----Approx.- th-7 Eastern...- ---w•Surface Seal-installed by <br /> ❑ Irrigation ,r- - <br /> Repair Work Done ❑ Type of P p H.P. State Work Done - <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 � i <br /> Depth Filler IVlaterial (Below 501 <br /> TYPE OF SEPTIC WORK:i NEW INSTALLATIONREPAIR/ADDITION ❑ DESTRUCTION 11 (No septic system permitted if public sewer is <br /> available within:200 feet.) i <br /> i t <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: t Number of..bedrooms_ �- <br /> i �• - --�- --- - <br /> � Character of soil to a depth of 3 feet: ``•,� Water table depth- —' <br /> r SEPTIC TANK ❑ Type/Mfg3Capacityn�.-; No.Compartments <br /> { b. ? ;a � Method of D1 ofsal <br /> PKG. TREATMENT PLT. ❑ ;,i - t r` <br /> Distance to nearest: Well Foundation 9— Property Line <br /> �.1 I. <br /> r LEACHING LINE ❑ No. &i ength of lines Tptal length/size ' <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line `V <br /> i SEEPAGE PITS C] Depth I Size <br /> Number <br /> ' .SUMPS. .--r-- - ❑ Distance-to nearest:---Well----- -Foundation-- �---�"-Property-tine <br /> DISPOSAL PONDS ❑ <br /> 1 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 sighature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> s compensation laws of California."Contractor's hiring or sub-contracting signature <br /> employ any person in such manner as to become subject to workman' <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 for all required inspections. Complete drawing on reverse side. ro <br /> Signed Title:�� awn Date: - <br /> FOR DEPARTMENT USE ONLY <br /> r <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final inspection by <br /> Date <br /> Additional Comments: <br /> p 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 /> a <br /> CK RECEIVED BY DATE PERMIT NO. <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> + EH 1324(REV.1/85) <br /> EH W28 <br /> t _ <br />