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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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. TMs 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'4)istrict.(- <br /> Job Address ® • City / Lot Size PM <br /> r + s <br /> r + , <br /> a <br /> Owner's Name Ad ress Phone <br /> Contractor's Name icense No. L Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ • 4 SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER }INES'1 DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> - i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1 Diafiof Wellkasing --" <br /> It <br /> 11 Domestic/Private ❑ Gravel Pack ❑ Tracy r Type of Casing f4t Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal talled b4 <br /> El <br /> U <br /> Repair Work Done Type of Pump. ) s <br /> H.P. ..State Work Dane <br /> Well Destruction ❑ Well Diameters 4 Sealing Material'(top 501 l* <br /> %fit y, Depth ' Filler Material#(Below 50'), <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> installation will serve: ResidencAber <br /> Commercial— Other <br /> Number of living units: � of bedrooms <br /> Character of soil to a depth of 3 feet: Water tab! depth <br /> SEPTIC TANK ❑ Type/Mfg ��� Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well /j1P Foundation /go- Property Line <br /> fi <br /> LEACHING LINE No. & Length of lines 40 Total length/size <br /> FILTER BED ❑ Distance to nearest: ell tin Foundation ___ Property Line` <br /> SEEPAGE PITS ❑ Deptha Number <br /> SUMPS 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 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 /> The applican t rrequir m ctions. Complete awing on reverse side. i J <br /> 7111 <br /> Signed Title: _Date: /X <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date L ° _ _ Area <br /> Pit or Grout Inspection by Date Final Inspection byT_ �— Date <br /> Additional Comments: 67 <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 /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"N0. <br /> INFO CASH <br /> + EH 13-24{REV.10!831 L S O <br /> EH 1428 <br />