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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> a <br /> 1601 E. HAZEL T ON AVE:, STOCKTON, CA 4 <br /> Telephone (209).466-6781,_ F } <br /> PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> _»> (Complete in Triplicate) 4 <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 /l /C/` W t I R A City Lot Size PM �- <br /> Owner's NameL �Address M> Phone <br /> Contractor '�W Address License No. Phone <br /> F WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER <br /> DISTANCE TO NEARE TIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE + <br /> FOUNDA AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED"USE TYPE OF WELL P AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca a. of Well Excavation Dia. of Well Casing <br /> IR Domestic/Private ❑ Gravel Pack ❑ Tracy Type o Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Sea Type of Grout r <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by k <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 50'1 <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> il <br /> Installation wl serve: Residence Commercial <br /> mercial— Other <br /> Number of living units: , Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth I <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 17 Method of Disposal <br /> t. <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. 6 Length of lines Total length/size 1 <br /> FILTER BED ❑ Distance to nearest: Well Foundation 'Property Line F #! <br /> SEEPAGE PITS ❑ Depth Size Number I <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line i <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 rformance of the work for which this permit is issued,I shall employ persons subject ti workman's compensa- <br /> tion laws of California." <br /> The applicant mu fo all req n cti late drawing on reverse si ..-. ....,,,,^,,;I <br /> Sign Titl Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area " <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk Alffi Ill ❑ 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 95201FEE , <br /> I <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. } <br /> + EH 13-2A/REV.s/A51 <br /> EH 1428 �-1 /�' <br />