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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ; <br /> 1601 E. HAZELTON AVE., STOCKTON, CA j <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 Address <br /> f ©(`J City/—;*w Lot Size PM <br /> Owner's Name Address Phone <br /> Air <br /> Contractor's Name License No. d Phone ` <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ „ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR a OTHER ❑} y <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES { DISPOSAL FLD. PROP. LINE <br /> FOUNDATION 4 AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIO�'SPECIFICATIONS _- <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> WrtOmestic/Private ❑ Gravel Pack} ❑ Tracy Type of Casing" Specifications V <br /> ❑ Public Ll Other <br /> El-Delta Depth of Grout Seal Type of Grout O <br /> ❑ Irrigation ---Approx. Depth A❑ Eastern Surface Seal Installed by F <br /> Repair Work Done 9 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter ' Sealing Material (top 50'1'' <br /> `Depth Filler Material (Below 50'j/ <br /> TYPE OF SEPTIC WORK:- NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> E available within 200 feet.) 1 <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 it Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ ' 1 •" :,r Method of Disposal <br /> Distance to n9aL well Foundation Property Line <br /> LEACHING LINE ❑ No. & Leng"th of lines Total length/size <br /> FILTER BED ❑ ,Distance to nearest: Well Foundation Property Line <br /> - e <br /> }' SEEPAGE PITS­ ❑ bepth Siz— Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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's compensation laws of California."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." F <br /> The applicant I st call r ll required inspections. Complete drawing __avers He. <br /> Signed X L Title:;p�u�+`�'� Date: ee la <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date '/ __1? Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-36211 ❑ 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`NO." <br /> INFO <br /> + EH 13-24(REV.10/831 ��, ��. o a _ 7e'1/ <br /> EH 14-28 <br />