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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT f <br /> 1601 E. HAZELTON ON AVE., STOCKTON, CA. p <br /> Telephone (209) 466-6781 J <br /> PERMIT EXPIRES TYEAR 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. / fi �� y <br /> City 'v� 4 Lot Size I& PM <br /> Job Address <br /> j <br /> Owner's Name _ <br /> G Address d� r �� � ^� Phone <br /> s' t Address License No. Phone <br /> Contractor y <br /> TYPE OF WELL/PUMP: ;NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES. <br /> DISPOSAL FLO. ROP. LINE <br /> FOUNDATION AGRICULTURE WELL OT LL PVT5/SUMPS <br /> INTENDED USE TYPE OF?WELL PROBLEM AREA CON ON SPECIFICATIONS <br /> Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ MantecaRia. of Well Excavation <br /> acy Type of Casing Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack Type of Grout <br /> ["I Public Cl thr { ❑ Delta Depth of Grout Seal <br /> I I Irrigation �TV_e_._tPpPr5f1" <br /> . Depth l I EasternSurface Seal Installed byRepair Work Done p <br /> H P State Work Done— <br /> Well Des lon ❑ Well Diameter Sealing Material Stop 501 <br /> Depth i Filler Material (Below 50'1 <br /> c tam TYPE OF SEPTIC WORK: NEW INSTALLATION I'i REPAIR/ADDITION l 1 DESTRUCTION i sys <br /> alvailabpelwithin 200 feetitted if public sewer is <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 <br /> PKG. TREATMENT PLT. ❑ A Method of Disposal <br /> r Distance to nearest: Well Foundation Property Line <br /> f <br /> LEACHING LINE ❑. No. & Length of lines Total length/size <br /> r <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> x Property Line <br /> SUMPS Ll Distance to nearest: Well - Foundation p Y <br /> DISPOSAL PONDS <br /> I hereby certify that I have prepared this application and that the work will be done,,min accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local.Health-District. =Y- �— - �`�^ <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." <br /> The applicant must cal for all required inspections. Complete drawing on reverse side. <br /> Signed X 42 44 Title: Date: <br /> FOR DEPARTMENT USE ONLY L <br /> ' Date � � Area ` r <br /> Application Accepted by <br /> f <br /> r Date Final Inspection b ���y Date + <br /> Pit or Grout inspection <br /> Additional Comments: WU <br /> ❑ Stk 466-6781 El Lodi 369-3621 El Manteca 82 -7104 © Tracy 835 6385 <br /> I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.. P.O. Box 2009, Stk., CA 95201 <br /> FEE CK RECEIVED BY DATEF�n <br /> PERMIT NO. <br /> AMOUNT DUE AMOUNT REMITTED <br /> INFO 1 <br /> c� �'Z W+ EH 13-24(REV.11 n 51: • <br /> EH 14-26 <br />