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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 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 Joaquin County Ordinance No. 549 for sewage or No. 1882 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address <br /> �i�QQQtff"y"' Lot Size PM <br /> Owner's Na Address l <br /> ° Phone <br /> Contract - Address <br /> rG. License Phon- <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ <br /> DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. •PROP, LINE - <br /> FOUNDATION AGRICULTURE WELL ��OTIJfA WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONST TION SPECIFICATIONS <br /> © Industrial ❑ Open Bottom ❑ Manteca ra. of Well Excavation <br /> LJDomestic/Private ❑ Gravel Pack ❑ T Dia. of Well Casing 11-1 <br /> Type of Casing Specifications <br /> i'1 Public FI Other _ Delta Depth of Grout Seal <br /> I I Irrigation _A Type of Grout _ <br /> Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ pe of Pump H P <br /> State Work pane <br /> Well Destructio Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br />�1 OF SEPTIC WORK: NEW INSTALLATION [1 REPAIR/ADDITION l I DES IHUCIIO Wo septic system permitted if public sewer is <br /> Q\ Installation will serve: Residence— Commercial_ Other available within 200 feet 1 <br /> Number of living units: Number of bedrooms <br /> �\ Character of s0ii to a depth of 3 feet: <br /> SEPTIC TANKWater table depth <br /> ❑ Type/Mfg <br /> PKG. TREATMENT PLT. ❑ Capacity No. Compartments <br /> 1 <br /> Method of Disposal <br /> Distance to nearest; Well Foundation Property Line <br /> 3 <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED 11 Distance <br /> length/size <br /> Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS I I Depth Size <br /> SUMPS 'Number <br /> Ll 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 rx-sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, <br /> tion laws of California." I shall employ persons subject to workman's compensa <br /> The applic must call for all required inspections. Complete drawing on re se side. <br /> Signed Title:' <br /> �} Date: <br /> FOR DEPAR7MEN7 USE ONLY <br /> Application Accepted by _/, <br /> Date Area <br /> Pit or Grout Inspection by Date <br /> Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ 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 AMOUNT DUE197!lit <br /> INFO ,( RECEIyED BY DATE PERMIT'NO. <br /> +.EH 14.21IREV.IiK51 _(Jd <br /> EH 1/�2a Jl '/y C1X (Xl <br />