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APPLICATION�FOR PERMIT <br /> SAN JOAQUIN LOCAs. HEALTH DISTRICT � <br /> 1601 E. HAZELTON AVE., STOCKTON, CA .. <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES-11 YEAR FROM-DATE ISSUED n <br /> * *. (Corhplete 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 /> j Pl (� <br /> Job Address t City Lot Size PM <br /> Owner's Name Address Phone <br /> Contractor's Name scan .No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D <br /> y PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANKI SEWER LINES - DISPOSAL FLD. PROP. LINE <br /> FOUNDATION; AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE j.TYPE OF WELL PROBLEM AREA_ -_C.ONSTRUCT_ION•SPECIFICATIONS <br /> F ❑ Industrial E3 Open Bottom -❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ' _ Specifications <br /> ❑ Publics❑ Other ❑ Delta -Depth of'Grout Seal Type of Grout <br /> ❑ Irrigations —Approx. Depth O Eastern Surface Seal Installed by <br /> Repair Work Done ,(❑"tType•of Pump r H.P. State Work Done <br /> Well Destruction ❑4, Well Diameter F Sealing Material Itop 50' <br /> k Depth Filler Material IBela ') ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ :REPAIR/ADDITION 9 DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> -4 � ri Fy available within 200 feet.) 42 <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:. 1 " Water table depth <br /> a' SEPTIC TANK ❑ Type/Mfg j Capacity 'No, Compartments <br /> PKG. TREATMENT PLT. 04 n F Method of Disposal' <br /> t <br /> Distance to k Barest: � Well <br /> Foundation Property Line <br /> LEACHING LINE No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to dearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth i Sizes d 1fJ<>� Number <br /> SUMP 11Distance 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 i <br /> rules and regulations of the San Joaquin-Local Health District. 1 <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." 4 <br /> The applicant rpust CAI for all reqM71npections. Com eta drawing on rWdMe side. <br /> F <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY l <br /> Application Accepted by Date S �? " - A a ' <br /> Pit or Grout Inspection by Date Final Inspection f_v Date <br /> dditional Comments:,.V'V" �� <br /> Stk 466-6781 ❑ Lodi 369621 Manteca 823-7104 El.Tr cy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Cf. Box 20.09, Stk., CA 9G201 <br /> FEE AMOUNT DUE ;� AMOUNT REMITTED CASH <br /> RECEIVED BY DATE PERMIT"NO. <br /> INFOc <br /> + EH1324(AE5l.10193Y <br /> EH 1426 ? <br />