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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 /> 1 <br /> (Complete in Triplicate) <br /> ;;... <br /> ? Local Health District for a permit to construct and/or install the work herein described.This aPPfic <br /> Application is hereby made to the San Joaquin ateon 1s <br /> o.549 for sewage or No.1862 for well pump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance N <br /> Local Health District. <br /> City l I ` f 4Lot Size PM <br /> Job Address �� �� <br /> 1 l S'? Address Phone T I <br /> _ Owner's Name �' t + � <br /> f {� i Pfione� r `/ <br /> Contractor <br /> //, Address r License No. <br /> "TYPE OF WELL/PUMP: NEW WELL LiWELL REPLACEMENT ❑ bESTRUCTION CO- W <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> F1 Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation <br /> Type <br /> of Casing Specifications <br /> ❑ Domestic/Private 1-1GravelPack ❑ Tracy g T of Grout <br /> ❑ Public El Other EJ Delta Depth'of Grout Seal y� qs-N <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> H P , State Work Done <br /> Repair Work Done LlType of Pump rte_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50. <br /> 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 /> 111 Installation will serve: Residence Commercial— Other f <br /> Number of living units: Number of bedrooms Water table depth!` <br /> r Character of soil to a depth of 3 feet: <br /> Capacity No. Compartments <br /> SEPTIC TANK .❑. Type/Mfg - Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> i LEACHING LINE LlNo. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line . <br /> i SEEPAGE PITS ❑ Depth Size Number <br /> ❑ Distance to nearest: Well *' Foundation Propertjit-ine <br /> SUMPS 1 <br /> DISPOSAL PONDS ❑ <br /> # rk will be done in accordance with San Joaquin county ordinances, <br /> I hereby certify that I have prepared this application and that the wostate laws, and <br /> rules and eegulations 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, l shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contra <br /> ctofs 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 empldy persons subject to workman's compensa <br /> tion laws of California." <br /> The applicant s call f all r uere i spections. Complete drawing on reverse side. + <br /> Signed <br /> Title:— _ ` — Date: <br /> FOR DEPARTMENT USE ONLY `J�� <br /> Date / Area <br /> ' Application Accepted by <br /> i Pit o Grout;I �Iction by <br /> Date .Final Inspection b Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 835-638,5 <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' CASH r RECEIVED BY DATE PERMIT"NO. <br /> INFO <br /> r + EH 13-24(REV.1/55) <br /> EH 14.28 <br />