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APPLICATION FOR PERMIT <br /> f <br /> r J�)t3j SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -P,1,1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> 1 -tilt <br /> C� RMIT 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. <br /> Job Address �W <br /> City Lot Size PM <br /> �n r <br /> Owner's NamPhone <br /> w S <br /> Contractor's Name License No. Phone J <br /> TYPE OF WELL/PUMP: NEAWELL REPLACEMENT EJ DESTRUCTION EJ <br /> PUMP INSTALLATION ;1_1 SYSTEM REPAIR ElOTHER ElDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP' LINE <br /> 44 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO <br /> ❑ IrZdGstrial —❑ O`geFi Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public 11 Other El Delta Depth of Grout Seal Ty of Gr ut <br /> El Irrigation --Approx. Depth 11East rn S�urfac�J S�eal Installed by tp <br /> Repair Work Done Ll Type of Pump ~� W.P. State or Done <br /> Well Destruction Well Diameter Sealing Material {top 501 <br /> pgpth _ rller Material (Below 501 V <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.l <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. ❑ 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 ❑ Depth 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. <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 apporion mple drawing on reverse side. <br /> Signed <br /> Title: Date: fZ <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 12_6_JAre, <br /> /21/r- f <br /> Pit or Grout Inspection by Date �3 Fina! Inspection by Date <br /> Additional Comments: <br />` ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 5-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. <br /> 4 k <br /> + 4281REV.16l931 I 13 '83-13 <br /> EH 7 ��7 - <br />