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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone 12091 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 �o City Lot Size PM <br /> Owner's Name ' tldress <br /> Phone 117Y, <br /> Contractor's Name <br /> -COA License Na. Phone ��J <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ElDESTRUCTION ❑ <br /> PUMP INSTALLATION X SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD. PROP. LINE j <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i <br /> INTENDED USE `�' TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial C1Open Bottom C1Manteca Dia. of Well Excavation Dia. of Well Casing <br /> r <br /> Domestic/Private ❑ Gravel;Pack ❑ Tracy Type of Casing Specifications <br /> l <br /> Ll Public E] Other 'I - ❑ Delta, Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx.:.Depth 1❑ Eastern Surface Seal Installed by— <br /> Repair <br /> y Repair Work Done ❑ Type of Pump H•P• I State Work.Done <br /> PA..Oy2z� 81 <br /> Well Destruction ❑ Well Diameter --,Sealing Material-(top 50') <br /> SLIA JAI /1/ !.0 <br /> I Depth E Filler Material (Below 501 GLtJ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIOM❑- REPAIRlADDITION [I DESTRUCTION El (No septic system permitted if public sewer is <br />'l available within 200 feet.) <br /> Installation will serve: Residence Commercial�" Other <br /> Number of living units: Number-of-bedrooms - —� -.•.- -- - T '� - <br /> Character of soil to a depth of 3 feet:' Water table depth <br /> t f" I Ca aci No. Compartments <br /> SEPTIC TANK�� ❑ Type/Mfg P tY <br /> PKG. TREATMENT PLT. <br /> ID <br /> of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> r r � <br /> LEACHING LINE d No. & Length of lines Total length/size <br /> FILTER BED s❑ `Distance'to nearest:,, Well FoundationProperty Line r <br /> SEEPAGE PITS ODepth ° Size Number <br /> SUMPS - ❑ Distance to nearest:— ,Well--.Foundation .Property Line . <br /> 1 DISPOSAL PONDS ❑ <br /> I 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 t <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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 at call for al require inspections. Complete drawing on r verse side. <br /> Signed J Title: r✓'�2 Date: <br /> FOR DEPARTMENT USE ONLY <br /> F Application Accepted by Date 7-47 Area <br /> Pit or Grout Inspection by Date Final Inspection.by ate <br /> itional Comments: <br /> tk 466-6781 ❑ Lodi 369-3621 El Manteca 823-7104 ❑ Tracy 8;35-63 5 <br /> Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> Y� <br /> FEEAMOUNT DUE . AMOUNT <br /> REMITTEDCK RECEIVED BY DATE PERMIT'N0. <br /> INFO <br /> +EH 1324 IREV.14183} <br /> EH 1428 <br />