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j <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ' 1601 E. HAZEL T ON AVE., STOCKTON, CAI/til I <br /> Telephone (209) 466-6781 UU <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. 1862 for well/pump and the Rules and Regulations of the San Joaquin { <br /> Local Health District. t , <br /> J � <br /> Job Address d e;f n City Lot Size s PM <br /> Owner's Names`� � �� o� Address 1 Phone <br /> Contractor's NameLicense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL 171WELL REPLACEMENT ❑ DESTRUCTION [I] i <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i <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 [DOpen Bottom ElManteca pia. of Well Excavation bio. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack�P ❑_Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other. , ElDelta . _ Depth of Grout Seal Type of Grout <br /> III Irrigation _1Approx.:Depth ❑ Eastern + Surface:Seal Installed by ; <br /> Repair Work Done ❑ Type of Pump H.P. 0�011 State Work Done <br /> Well Destruction ❑ Well Diameter Sealing MaierialAtop 501 <br /> Ai <br /> Depth Filler Material.,(Below 50'1 rn <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑:•,_DESTRUCTION LJ (No septic system permitted if public sewer is VU <br /> f 1available within 200 feet.) <br /> Installation will serve: Residence vJir Commercial -Other�� <br /> Number of living.units: __I--__I-- Number of bedrooms <br /> W <br /> Character of soil to a depth of 3 feet: ' <br /> Water table depth <br /> SEPTIC TANK 1!1' Type/Mfg f Capacity <br /> No. Compartments z <br /> PKG. TREATMENT PLT. ❑ ' Method-of Disposal <br />` Distance to nearest: Well )QC)!f Foundation /C�� Property Line <br /> — ' <br /> E LEACHING LINE d No. & Length of lines 'A'— ��� .r Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth --Size 1 Number <br /> SUMPS ❑ Distance to nearest: Well 'f Foundation Property Line <br /> DISPOSAL PONDS Ely <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 /> k 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 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 call for all quired inspections. Complete drawing on re arse side. <br /> ' s <br /> Signed Title: Date: ' Z� <br /> ,. <br /> /a/ w•• <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by vv Date <br /> Pit or Grout Inspection by I, Date Final Inspection b Date <br /> Additional Comments: JI <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> P <br /> FEE AMOUNT DUE �i AMOUNT REMITTED CASH R11 ECEIVED BY DATE PERM1T'NO. <br /> INFO p <br /> + EH 13-24 IREV.10/631 <br /> EH 1426 <br />