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i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 i <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. f <br /> Job Address City Lot Size y PM <br /> Owner's Name Address Phone / <br /> -�q 7 <br /> Contractor's Name icense Na. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEM NT DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAI ❑ 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 /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx.Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION tr REPAIR/ADDITION ❑ DESTRUCTION ❑ (No 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: Wafer table depth <br /> SEPTIC TANK ❑ Type/MfgCapacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Z Method of Disposal <br /> Distance to nearest: Well 119P FoundationProperty Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest:�ell/Q Q Foundation 990 Property Line <br /> SEEPAGE PITS ❑ Depth ' Size .tel Number <br /> SUMPS ❑ Distance to nearest: Well I&A Foundation i1A 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. <br /> Home owner or licensed agent's signature certifies the following:yl 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 whicWthis permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." r <br /> The applica_ r ire ns cons. Complete dra on r� a side. <br /> Signed rtle: Date: <br /> FOR DEPARTMEN U LY <br /> Application Accepted by Date Area <br /> i <br /> Pit or Grout Inspection by` Date - Final Inspection by Data <br /> Additional Comments: <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE �+ PERMIT`NO. <br /> + EH 13-24(REV.10183) L4_S7- <br /> EH 1426 a�d <br />