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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. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> i <br /> Job Address + City Lot Size PM <br /> SGS-9dL7 <br /> Owner's Name Address Phone b <br /> Co Address License iVo. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE e <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 /> 71 Domestic/Private ❑ Gravel-Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public Cl Other } ❑ Delta Depth of Grout Seal Type of Grout —. <br /> I I Irrigation --Approx. ,Depth { I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work one_ <br /> Well Destruction Well Diamet r if Sealing Material (top X50') <br /> Depth Filler Material (Below 5011 <br /> {� I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [:I REPAIRIADDITION l I DESTRUCTIO (No septic system permitted if public sewer is `a <br /> I vailable within 200 feet.) r <br /> Installation will serve: Residence_t Commercial --Other- <br /> Number <br /> Other= <br /> Number of living units: _..Number 6f'bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg} Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: ' Well Foundation Property Line <br /> SEEPAGE PITS ['I Depth ;: o- Size 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. i <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 applioa mus Call for ajl require i pections. Complete drawing on reverse side. <br /> Sign Title: "J Date: <br /> FOR TMENT USE ONLY <br /> Application Accepted by Date Area Q <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <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..Hazolton Ave., P.O. Box 2009, Stk., CA 95201 <br /> s �� Lf <br /> V <br /> FEE AMOUNT DUE MOUNT REMITTED CA2H RECEIVED BY DATE PERMIT•No. <br /> INFO <br /> + 13-24(REV. y <br /> EH 11-2 <br /> '' <br />