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APPLICATION FOR PERMIT <br /> • <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA APR 2 <br /> Telephone (209) 466-6781 ENVIRONMENTAL HSA,;, t. � <br /> [PERMIT EXPIRES 1,YEAR FROM DATE ISSUEDter-' <br /> PERf�iIT/SC:R�iI#.- r <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 Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> City �'- " Lot Size PM <br /> Job Address <br /> Phone 133 <br /> Owner's Name <br /> r !Address / <br /> r <br /> Contrac <br /> tAddress Address , sic C.� ' License No. a2 7 Phone <br /> TYPE WEL UMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LI <br /> PUMP INSTALLATION � SYSTEM REPAIR LJOTHER fl <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA I CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ­❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> r Public El Other � ❑ Delta Depth of Grout Seal Type of Grout - <br /> IA irrigation —Approx. Depth . I.I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump fA �^ - H.P. @ State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') 1 <br /> l <br /> • • Depth Filler Material (Below 50'1 6 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l 1 DESTRUCTION I I (Nseptic <br /> s tem <br /> ys <br /> ail (thin 200 feet.) if public sewer is . <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: ' Number of bedrooms <br /> Character of soil ta'a depth of 3 feet Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> n Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE LINo. & Length of lines Total length/size <br /> FILTER BED ❑ Distance r 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 ❑ <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_Joaq'uin Local Health District. - - <br /> "I certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: <br /> employ any person in such manner as'rto 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 /> The applicant must call or all required inspections. Complete drawing on reverse side. <br /> 3 g;2 <br /> Signed X Title. Date: <br /> F DEPARTMENT USE ONLY <br /> a <br /> f Application Accepted by <br /> Date a rea <br /> Pit or Grout Inspection by Date Final inspection by Date <br /> Additional Comments: <br /> ❑ Stk .466-6781 ❑ Lodi 369-3621 ❑ Me nteca $23 7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Envir. nmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUET AMOUNT REMITTED CASH RECEIVED BY DATE PERMiT'NO- <br /> INFO <br /> s o g ~ 1 <br /> r.EH13-24iREV.1/851 a7C, <br /> EH 14-26 <br />