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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 s <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 /> 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> made in compliance with'San Joaquin County Ordinance No. <br /> Local Health District. <br /> �,' i - C. <br /> Job Address - <br /> City Lot Size -7 <br /> Owner's Name 1[ ) C fRddresss Phone <br /> Contractor L � ddress a"50 'V\J icense No.q_ �Phone -� a <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 F1 Open Bottom-- —d-Manteca–�--�--�-Dia-of•WeII-Excavation--�^– Dia. of Well Casing y <br /> Ll Domestic/Private E1 Gravel Pack El Tracy Type of Casing Specifications <br /> ❑ Public i] Other ❑ Delta Depth of Grout Sea] Type of Grout <br /> 1s <br /> ❑ Irrigation - ---Approx. Depth ❑ Eastern Surface Seal Installed by C <br /> Repair Work Done El Type of Pump. H.P. % =` State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION RV ,IWADDITION-❑ , 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 bgdrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> IICa act I—No.._Compartments -.., <br /> SEPTIC TANK t2-rType/Mfg. § p ryQ l <br /> PKG. TREATMENT PLT. ❑ �: <br /> k Method of Disposal <br /> Foundation y Property Line <br /> Distance- <br /> F 4 <br /> to-nearest':"--��Wall -t _ f <br /> LEACHING LINES ❑. No. & Length of lines � _,.. 'fr Total len th/size I <br /> z_ <br /> f FILTER BED s once to nearest: Well Foundation Property Line" <br /> 1 4. <br /> i <br /> SEEPAGE PITS ❑ Depth Size Y - —Number <br /> SUMPS ❑ 'Distance fo n`earesv Well Foundation Property Line <br /> DISPOSAL PONDS ❑ _ <br /> 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: 19 certifV'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 oompensation 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 /> ti— `9aw�ss of California." <br /> The applic� u t call for ]I re ired n pec7fco <br /> mplete drawling onr verse sid <br /> Signed Title: _.� Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Date <br /> Pit or Grout Inspection by Date��' g Final Inspectio y <br /> y £ ° <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy . <br /> Applicant - Return all copies to: Environmental Health Permit/Services 16D1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. <br /> INFO <br /> + EH13.241AEV.t/s51 <br /> EH 14-26 <br /> t <br />