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APPLICATION kOR PERMIT <br /> j SAN JOAQUIN LOCALOHEALTH DISTRICT <br /> r 1601 E. HAZELTON AVE., STOCKTON, CA <br /> ,. Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,. <br /> t -_ k (Complete in'Triplicate) t ` <br /> Local Health District for a perrrfit to construct and/or install the work herein described.This application is <br /> Application is hereby made to the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welt/pump and the RulesandRegulations of,the San Joaquin <br /> Local Health District, <br /> Lot Size . . .. PM <br /> City X- <br /> Job Address h <br /> ! Phone <br /> Owner's Name Address <br /> Contractor O Address <br /> i^IF License No. Phone <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMEN ❑ DESTRUCTION ❑ <br /> -PUMP INSTALLATION Q- <br /> SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ In , Specifications <br /> Type of CasingType <br /> k <br /> l�pomesticlPrivate " F-1 Gravel Pack ❑ Tracy Type of Grout <br /> ❑ Public L-3 Other <br /> I ❑ Delta Depth of Grout Seal . <br /> ❑ irrigation ---Approz�De Eastern Surface Seal Installed by, <br /> ate Work Done <br /> Repair Work Done St Type of Pump (� <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 L 1 <br /> Depth I Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION Ll 16N <br /> system rented if public sewer is <br /> e _ <br /> i <br /> r <br /> Installation will serve: Residence'I Commercial_,Other_ ��s <br /> Number of living units: Number of bedrooms r <br /> Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK ❑. Type/Mfg Capacity <br /> t �_.� Method of Disposal <br /> ❑ <br /> PKG. TREATMENT PLT. <br /> DistanceJo nearest: Well Foundation Property Line, <br /> l <br /> �{ <br /> LEACHING LINE ❑ No. & `Length of lines Total length/size <br /> Property Line <br /> FILTER SED ❑ Distant i to nearest: Well Foundation . <br /> r' <br /> SEEPAGE PITS ❑s Depth <br /> ' Size Number <br /> SUMPS - ❑. Distance to nearest: Well Foundation' Property Line''` <br /> DISPOSAL PONDS ❑ <br /> h7ereby certify that I have prepared this application and that the work will be done in accordance with San Joaquincounty ordinances, state laws, and <br /> I <br /> rules and regulations of the San Joaquin Local Health District <br /> Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work torwhich 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: 1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa <br /> g' I .c-.. <br /> tion laws of ia." # J <br /> The plicant m t call for all req rnsppeecti s.Com to:drawing onrr side. <br /> Title: ` �? Date: <br /> Signed X r ..;. <br /> R DEPARTMENT USE ONLY <br /> n, A�� Area - <br /> Date <br /> I Application Accepted by � <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date% <br /> Additional Comments: ' <br /> ❑ Stk 466-6781 ❑ 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 <br /> 1 � , <br /> FEE CK RECEIVED By DATE PERMIT NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> ♦ EH 13-24(REV.t/H 5) - ` - <br /> I EH 1 4-26 - <br />