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APPLICATION FOR PERMIT . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE.T ON AVE., STOCKTON, CA V <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES TYEAR 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 Joaqui County Ordinance No. 549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address "' i © Lot Size PM <br /> t <br /> Owner's N ��� ress one <br /> «<2KD ..� <br /> Contractor (?"Ad es fit~ License No?��Y� Phone <br /> TYPE OF WELL/PUMP: 4f 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> fl Public Cl Other M Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ <br /> t <br /> Well Destruction ❑ Well Diameter Sealing Material [top 601 <br /> Depth t - Filler Material 16elow 501 r" <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION t I DESTRUCTION Y.,1 (No septic system permitted if public sewer is <br /> available within 200 feet.1 l" <br /> Installation will serve: Residence_ Commercial— Other r <br /> Number of living units: Number of bedroomsf . <br /> Character of soil to a depth of 3 feet: Water table depth 'y <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line j. <br /> LEACHING LINE ❑ No. & Length of lines Total length/size t <br /> FILTER BED ❑ Distance to nearest: -Well Foundation Property Line <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 y <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." Contractors 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 /> ;Theappllicant must call for aE required inspections. Complete drawingcf:on'`r�everse�side. <br /> e Title:�� / " =) r1 <br /> Al <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date �--' ` Area <br /> • i <br /> Pit or Grout Inspection by to { Final Inspei <br /> f�by Date <br /> Additional Comments: "'- <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Aanteca 1 823-7104 ❑ Tracy 5-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2109, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> + EH 13-24 1REV.t i n 51 ��'1 — — �7 <br /> EH 14-26 UUf I <br />