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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL'HEALTH DISTRICT <br /> 1601 E. HAZEL TON AVE., STOCKTON, CA <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 Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address City" C1 Lot�Size PM <br /> Owner's Name '{ s <br /> :Phone <br /> Contractor AddressLicense No.��_Phone <br /> TYPE OF WELL/PUMP: V NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> tj <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 /> I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation _Approx! Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top SO') <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO o septic system permitted if public sewer is <br /> + _ Other = available within 200 feet.) <br /> { Installation will serve: Residence. ,Commercials- - - .:� . <br /> Num er o6`fliving units: Number of bedrooms <br /> t Character of soil to a depth of 3 feet:' Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ 1 Method of Disposal <br /> Distance'to nearest: Well Foundation Property Line <br /> j+ <br /> � 1 <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance fo nearest: Well Foundation Property Line <br /> I <br /> SEEPAGE PITS ❑ Depth .$, Size <br /> Number <br /> ' SUMPS ❑ Distance too 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 /> F 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." 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 applican ust call for all equired ins ctions. Complete drawing on reverse side. <br /> !! Signed Title: Date: <br /> I <br /> FO DEPARTMENT USE ONLY <br /> 4 <br /> Application Accepted y Date Area g <br /> i <br /> Pit or Grout Inspectio Y Date Final'Inspection by Date Z <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ;,` ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environ'rental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,+.Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE �.� AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> h:r <br /> EN 144 - <br /> { EH IREV.7/8 Sl - . 3S•vim a43� ND <br />