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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 1SSUED`'n t!' r 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 H compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. -- ... :' Via. � <br /> f 1 <br /> Job Address (D <br /> City t Lot Size 'PM <br /> r ' <br /> Owner's Name <br /> Address .(11 <br /> Phone 7" � <br /> Contractor- Address <br /> TYPE OF WELL/PUMP: �`�— 1Z"'�°license No J �(, ' Phone�S <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION (i?� SYSTEM REPAIR.❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER ElSEWEA LINES — DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL . OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS- <br /> 0 PITSlSUMPS <br /> Indu al ❑ Open Bottom ❑-Manteca <br /> Dia. of Well Excavation Dia. of Well Casing <br /> omestic/Private ❑ Gravel Pack ❑ Tracy <br /> y Type of Casing Specifications <br /> ❑ Other ❑ Delta Depth of Grout Seal <br /> ❑ IrrigationType of Grout <br /> ---Approx. Depth C] Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump � H P %_ <br /> Well Destruction L3 Well Diameter State Work Done Q <br /> Sealing Material (top 50') <br /> Depth Filler Material IBelow,5011 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ ,REPAIR/ADDITION ❑ DESTRUCTION ❑ ;No septic system permitted if public sewer is <br /> f <br /> Installation will serve: Residence— � <br /> Commercial— Other available within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANKWater table depth <br /> ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. [I <br /> Distance to nearest: Wel! Foundation Method of Disposal <br /> Property Line y <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BEDTotal length/size <br /> ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAbE'PMF ❑ Depth - Size <br /> Number <br /> SUMPS <br /> ❑ Distance to nearest: Well Foundation *. _. <br /> DISPOSAL PONDS F1 - Property Line yy <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 applicant must a!I for all req 'ed inspections. Complete drawing on reverse side. <br /> Signed Title: <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by A� Date_ <br /> ._ Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Date ^ "L <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I <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# <br /> INFO CASH RECEIVED BY DATE. PERMIT"NO. <br />+ EH 13-24(REV.t/'13 57 ` �� <br /> EH 14-26 <br /> ��j�E40 q lq <br />