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j APPLICATION FOR PERMIT <br /> f SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> + PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> . I <br /> (Complete in Triplicate) =.x <br /> E <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 I <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 /> I Local Health District. <br /> Job Address <br /> } City. Lot Size PM I <br /> i ( S <br /> Owner's Name t ddres i� "'� o Phone <br /> -r <br /> Contractor's Name License No. '' one <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 8-' 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 /> r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation _—Approi, Depth 4 Eastern Surface Seal Installed by <br /> .l - <br /> Repair Work Done ❑ Type of Pump W.P. StateW rk Done <br /> Well Destruction El Well Diameter Sealing Material (top 50'1' <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence` Commercial_ Other <br /> Number of living units: Number of 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. ❑ I Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED - ❑ Distance to nearest: Well Foundation Property Line <br /> I <br /> SEEPAGE PITS ❑ Depth 1 Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I 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 call for all requd' inspections. Complete drawing on reverse side. <br /> Signed ] Title:_� .rs� Date: <br /> FOR DEP TMENT USE ONLY <br /> Application Accepted by Date Area <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 <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 REMITTEDC K RECEIVED BY DATE. PERMIT-NO. <br /> } INFO. <br /> + EH 13-241REV.10/93} <br /> EH 14-26 <br /> i <br />