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APPLICATION FOR PERMIT <br /> SAN JOA2UIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> j Telephone (209) 466-6781 <br /> ;PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> 1 <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 /> -0y PM <br /> Job Address <br /> 2+` () � !' City Lot Size <br /> c/ti wl�L <br /> Owner's Name Address Phone <br /> Contractor's Name License No. Phone ' <br /> TYPE OF WELL/PUMP: V NEW WELL ❑ x WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial E3-,Open Bottom.......-Q Manteca- Dia.--of Well-Excavation --- ` -pia.-ofiWell Casing„ <br /> --- `""'"" ' e of Casin le Specifications <br /> w- w ravel Pack ❑ Tracy Type 9 <br /> ❑`Domestic!Private <br /> ❑ G <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> Ll Irrigation _Approx.;Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pumpl H.P. State Work Done <br /> Well Destruction ❑ i Well DiameterSealing Material (top 501 ' <br /> Depth j Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION iNo septic system permitted if public sewer is <br /> Y <br /> f vailable within 200 feet.) <br /> i , f <br /> Installation will serve: Residence— Commercial_ Other <br /> 5 <br /> Number of living units:) Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> I' SEPTIC TANK ❑ Type/Mfg' Capacity No. Compartments <br /> PKG. TREATMENT PLT. DI Method of Disposal <br /> t'.' Distance to nearest- Well Foundation Property Line <br /> i <br /> LEACHING LINE El No. & Length' of lines Total length/size <br /> FILTER BED s❑ Distance t6 nearest: Well Foundation Property Line <br /> SEEPAGE PITS #❑ Depth Size Number <br /> SUMPS + ❑ Distance to nearest: Wel! Foundation Property Line <br /> DISPOSAL PONDS ❑ I <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 /> I lowing: "I certify that in the performance of the work for which this permit is issued, I shall not,, <br /> Home owner or licensed agent's signature certifies the fol <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 Califo <br /> The applicant ca uir d inspections._Complete drawing on revers side: " <br /> Signed Title: <br /> Date: L 2-- 7- <br /> FOR DEPARTMENT USE ONLY �7 <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by .Date l <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 /> k <br /> FEE CK# RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> AMOUNT DUE' AMOUNT REMITTED CASH <br /> + EH 1324(REV.10183) <br /> i EH 1426 - <br />