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APPLICATION FOR PERMIT I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT L� <br /> 1601 E. HAZEL T ON AVE:, STOCKTON, CA �� <br /> Telephone,(209) 466-6781 bI r"� J <br /> ,`PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> #, (Complete in Triplicate) <br /> Application is hereby made tat <br /> he San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application <br /> made in compliance with San Joaquin Couhty 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 /> �f Lot Size PM <br /> Job Address '' E City <br /> Owner's Name <br /> f Address i � l z. Phone <br /> Corttractor Address License No. Phone <br /> TYPE OF.WELL/PUMP: NEW WELL.❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ .! <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES" DISPOSAL FLD. PROP. LINE <br /> �t <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSlSUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS iv <br /> Dia. of Well Excavation Dia- of Well Casing <br /> ❑ Industrial Ll Open Bottom 11 Manteca <br /> ❑ Domestic I Private ❑ Gravel Pack [1Tracy Type of Casing Specifications +, <br /> F1 Public n Other ❑ Delta Depth of Grout Seal Type of Grout <br /> Il <br /> I ! Irrigation _..Approx. Depth l i Eastern Surface Seal Installed by ,y <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done— !! <br /> Well Destruction ❑ Weil Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION (I REPAIR/ADDITION ( I DESTRUCTION (No septic system permitted if public sewer is ii. <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: Number of bedrooms !' <br /> ! <br /> Character of soil to a depth of 3 feet:) Water table depth <br /> SEPTIC TANK LD Type/Mfg <br /> Capacity ...No.--Compartments <br /> - - _ ' <br /> 1 r <br /> PKC. TREATMENT PLT. ❑ Method of Disposal <br /> I <br /> Distance to nearest: Well Foundation Property Line <br /> ' !I <br /> LEACHING LINT= ❑ No. & Length of lines Total length/size <br /> 3 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth I Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ �w <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 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 /> E The applican f all required ' spections. Complete drawing on verse side. s <br /> 4 i1 <br /> v' Signed r Title: Date: <br /> ��FO�RDEPA�lTiMENT USE ONLY r�J t ;�. <br /> Application Accepted b <br /> Data 1 Area / U 0 <br /> P Y ! <br /> PP <br /> Pit or Grout Inspecti y Date Final Inspection by Date . <br />' Additional Comments: J � o <br /> LJ Stk 466-6781 El Lodi 369-3621 ❑ Manteca 823-7104 #] Tracy 835-6385 �. <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I <br /> FEE AMOUNT DUE AMOUNT REMITTED H RECEIVED BY DATE f ERMITNO. <br /> INFO <br /> f EH 13,24 IREV.I/H 51 ��� Qd �►,p� r �� �/� �g� !_ <br /> i EH 14-28 ^' , <br /> f <br />