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APPLICATION FOR PERMIT <br /> I SAN JOAQUIN-LOCAL HEALTH DISTRICT <br /> 1601,E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone 1209) 466-6791 <br /> PERMIT EXPIRES 7 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 SaJoaquin C my 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 y,` f <br /> ` City Lot Size PM . <br /> Owner`s Name - Address - Phone <br /> Contractor Address <br /> License No Phone /J <br /> TYPE OF WELL/PUMP: NEWWELL ❑ WELL REPLACEMENT LJ DESTRUCTION CI� <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ r OTHER ❑ 1 <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout \` t <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by ill <br /> Repair Work Done ❑ Type of Pump H.P, State Work Done <br /> Well Destruction Well Diameter <br /> 6 Sealing Material (tap 50') <br /> Depth_f �+ Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other 1 <br /> Number of living units: Number of bedrooms <br /> Character of soli 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 /> :. V,1 <br /> SEEPAGE PITS ❑ Depth Size Number �h <br /> SUMPS ❑- Distance to nearest: Well Foundation Property Line f/ <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. i <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 appli ant must call for req red iYpecti6ns. Complete drawing on reverse s'de. <br /> SignedZ_ LTitle: <br /> • bate: <br /> FOR-DEPARTMENT USE ONLY <br /> Application Accepted by Date_ Area <br /> Pit or Grout Inspection by_424�: Date Final Inspection by Date <br /> 7 .. f <br /> Additional Comments; <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71641 > Tracy 835-6385 <br /> Applicant- RatuTm all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY <br /> INFOCAM DATE PERMIT'NO. <br /> + EH 13.74(REV.1/e5) ` ®� ,®® <br /> EH 1426 7�7 <br />