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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE. STOCKTON, CA <br /> Telephone (209) 466-678.1^ <br /> i <br /> PERMIT EXPIRES 1"YEAR FFOW©'ATE 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 /> - <br /> de 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 /> City <br /> t Size PM <br /> Job Address -A� <br /> Phone <br /> •Owner's Name <br /> ddress <br /> �` P <br /> Address License No. hone <br /> Contractor t <br /> TYPE OF WELL/PUMP: NEW WELL d WELL REPLACEMENT ❑ DESTRU I <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Q <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION +AGRICULTU LL OTHER WELL PITS/SUMPS <br /> { <br /> INTENDED USE TYPE OF WELL PROBLE A CONSTRUCTION SPECIFICATIONS <br /> © Industrial O Open Bottom anteca Dia. of Well Excavation Dia. of Well Casing <br /> Type of Casing Specifications <br /> ❑ Domestic/Private. ❑ Gravel Pack ❑ Tracy YP g <br /> 0 <br /> Cl Public f Othe F Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation �'^'^ '"� APp"x!Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. State Work Dade_ <br /> Well Destruc a Well Diameter Sealing Material (top 50'1 <br /> Repth 4 Filler Material {Below 50' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1] REPAIRIADDITION E DESTRUCTIO 1 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence? Commercial— Other <br /> Number of living units: Number of bedrooms <br /> r Water table depth <br /> Character of soil to a depth of 3 feet: <br /> i r Capacity Na. Compartments <br /> 4 SEPTIC TANK n Type/Mfg <br /> PKC. TREATMENT PLT. ❑ Method of Disposal <br /> Distancil to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Lerngth of lines Total length/size <br /> r <br /> FILTER BED 1-1Distanceto nearest:" Well Foundation Property kine <br /> sl <br /> SEEPAGE PITS I I Depth i� Size Number <br /> SUMPS L) Distancetonearest: Well Foundation _ Property Line <br /> DISPOSAL PONDS D <br /> 4 <br /> I hereby certify that f have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> } ng: "1 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 followi <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 st a for all re ed inspections. Complete drawing on reverse side. � � <br /> Data: <br /> -�Signed , <br /> Title: _ C1 � <br /> FOR DEPARTMENT USE ONLY <br /> F Application Accepted by Date Area <br /> Pit or Grout Inspec on D Final-Ins ct n by Date <br /> Additional Comments: } <br /> ❑ 5tk 466-6781 D Lodi, 369 3621q <br /> ❑ Manteca 823-7104 ❑ Tr cy 835-6385 rp � j��✓IJte�f� <br /> Applicant- Return all copies to:.Envir�amental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 a� <br /> 4FEE AMOUNT DUE i AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> 4 INFO930 <br /> EK <br /> +.EH 13.24(REV.I/n 5) �""" <br /> EH 14-28 <br />