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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> i Telephone (209) 466-6781 <br /> i PERMIT EXPIRES TY EAR FROM DATE ISSUED <br /> r <br /> (Complete in Triplicate) � <br /> Application,is hereby made to the San Joaquin Local Health Districtfar a permit to construct and/or install the work herein described.This application is <br /> k made in compliance with San Joaquin County Ordinance Na.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> ` Local Health District. <br /> lr i s I 14x- <br /> ?0 <br /> 4 `O ? <br /> > <br /> PN4� City <br /> Job Address"" <br /> a <br /> er's d Name <br /> ress,� l �"""" Phone <br /> Own <br /> # r <br /> Contractor <br /> Address ense No. Phone <br /> TYPE OF WELL/PUMP:. <br /> ,jNEW WELL ❑ WELL REPLACEMENT ❑ E DESTRUCTION 13i I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> {_ 4- DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> ` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> - r <br /> INTENDED USE r—TYPE OF'WELL °PROBLEM AREA CONSTRUCTION SPECIFICATIONS Q <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> EI Industrial P <br /> Specifications <br /> © Domestic/Private ❑ Gravel Pack- ❑ Tracy Type of Casing <br /> f7 Public n Other , 71Delta Depth of Grout Seal s <br /> Type of Grout <br /> I I Irrigation £, t "Approx. Depth l I Eastern Surface Seat Installed by <br /> -Repair Work Done [7 Type of Pump t H'PT - " State-Work-Done-= <br /> Sealing Material (top 50'1 t <br /> Well Destruction ❑ Welt Diameter - � 9 = <br /> Depth Filler Material (Below 501 <br /> TYPE: OF SEPTIC WORK: NEW INSTtALLA ION REPAIR/ADDITION { I DESTRUCTION i I (No septic system permitted if public sewer is <br /> available within 200 feet.) 1 <br /> 1k 5 <br /> op <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: -z- l "'"`" Water table depth <br /> ` SEPTIC TANK' ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Dis I <br /> Distance to nearest: Well Foundation Property Line <br /> i <br /> °'"� ' T <br /> � LEACHING LINE L-1 No. & Length of lines otal length/sizef <br /> FILTER BED Li Distance to nearest: ell Foundation Property`Line <br /> SEEPAGE PITS FI Depth Number <br /> l� ❑ Distance to nearest: Well Foundation_ Property Line <br /> r 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 /> 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 rmance 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 ust or, a uired s cti ns. Complet dr i on rev is <br /> Signed X itle: _-< CA,, <br /> FOR DEPARTMENT USE ONLY <br /> App ation Accepted by <br /> Date �r rou on b Date / rinal Inspection by <br /> Y <br /> Additional Comments: ' <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 935-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> b! <br /> FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO Q <br /> ........ .+ EH13-241REV.iiHSY rl. <br /> EH 14-26 I <br />