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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> 1601 E. HAZEL TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES "I 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.This application is <br /> made in compliance with San JoaquJln County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health ;A�. <br /> E17�tO ff <br /> Job Address City _ Lot Size M <br /> Owner's Name Address Phone <br /> Contractor's Name ,cense 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 /> FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA 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 r:�7 <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal _ Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material ftop 501 <br /> Depth Filler Material IBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic system permitted if public sewer is <br /> .�_ vailable within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other�� � <br /> Number of living units: —L— Number of bedrooms JL <br /> Character of soil to a depth of 3 feet: ��ryry Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity (L No. Compartments <br /> PKG. TREATMENT PLT. ❑ r Method of Disposal r <br /> Distance to nearest: Well 4/ Foundation Property Line 0 <br /> e <br /> LEACHING LINE No. & Length of lines Total length/size d <br /> FILTER BED ❑ Distance to nearest: Well Foundation --- Property Line <br /> SEEPAGE PITS Depth Size ►! LL �� Number <br /> SUMPS Distance to nearest: Well Foundation jig 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."Contractors hiring or subcontracting 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 t call for all requirinspections. Comple drawing on rev as side. <br /> Signed Title: Date: <br /> O�R} DEPART U E ONLY � <br /> Application Accepted by ' r" t Date Area ` <br /> Pit or Grout Inspection by Date �. Fina( Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT"NO. <br /> + EH 13-241REV.10!83} <br /> EH 14-28 3 '7 <br />