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APPLICATION FOR PERMIT a <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> all the <br /> rk herein describ . Thris <br /> cation is <br /> made nticompliance with Sano <br /> oJoaquin County Ordinathe San Joaquin nce No.District Health 549 for sewage permit <br /> 1862 for cweil/dpump atnd the Ras and R gulations of he Sant Joaquin <br /> Local Health District. <br /> 6 .6 <br /> Job Address —/ City <br /> Lot Size L1 �PM <br /> Owner's Name _ <br /> "Address. one "C0-0 <br /> " ��' Phone <br /> Contractor's Name -- License No. .rbc. -- <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT U DESTRUCTION LJ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK — SEWER LINES DISPOSAL FLD. PROP. LINE <br /> s FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom I ❑ Manteca Dia. of 11Vell.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 atop 501 _ <br /> Depth Filler Material {Below 501 G <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑,(No septic sh nem feet.)miitted if public sewer isavaC <br /> .. <br /> Installation will serve: Residence—. Commercial=_=Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: �. <br /> Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg (JQ Method of Disposal <br /> PKG. TREATMENT PLT.❑ <br /> Distance to nearest: Well Foundation Property Line f � <br /> LEACHING LINE ❑ No. & Length of lines Total length/size , <br /> Property Line E�ac� 1T" <br /> FILTER BED Distance to nearest: Well Foundation <br /> SEEPAGE PITS ❑ Depth <br /> Size ^^ Number <br /> SUMPS Q Distance to nearest: Well_ Foundation Property tine <br /> 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 <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 performanc 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 :pplic�for all required inspection win reverse side. Date:Signd <br /> FOR DEPARTMENT USE ONLY ' <br /> Date Area <br /> -- <br /> Application Accepted by <br /> r„ Pit or Grout Inspection by <br /> Date Final Inspection by \L Date —Z " <br /> Additional Comments: <br /> ❑ Stk 466-6781 [01L 369- Man -7104 0 ❑ 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 /> FEE CK RECEIVED BY DATE PERMIT"NO. <br /> INFO ttt '''AMOUNT DUE AMOUNT REMITTED CASH ( // <br /> +EH 1324(REV.10/83) 0 <br /> EH 14Q8 ICZN <br />