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APPLICATION FOR PERMIT <br /> r �F <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i ON AVE., STOCKTON, CA ®� <br /> !'[ Telephone (209) 466-6781 <br /> If PERMIT EXPIRES TYEAR FROM DATE ISSUED tlaIj <br /> -N-rkal-aI <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District far a permit to construct and/or install the work eh rein de nbed. This application is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin <br /> ri <br /> Local Health District. <br /> Job Address c ,�.+� City Lot Size ` PM <br /> Owner's Name 9,t ddress Phone <br /> Contractor Address License No. Phone <br /> E OF WELL/PUMP• NEW WELL.❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO REST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> OUNDATION AGRICULTURE WELL OTHER WELL PIT PS ! <br /> INTENDED USE TYP WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Type aSpecifications n <br /> 1`i Public Cl Other th of Grout Seal Type of Grout — '�Sa <br /> o --Approx. Depth I ] Eastern Surface Sea _ b ' _.._ <br /> Repair Work Done 0 Type of Pump H.P. State Work one <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material {Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION l I 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 bedrooms + <br /> Character of soil 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 /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS ❑ Distance to nearest: 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: "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 shalt employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant ust cat for all require inspections. CompleM drawing on reverse side. <br /> SignedX Title: Date: �_ f r / <br /> Fp Rt4RTMENT USE ONLY <br /> Application Accepted by Data 1^ r Area <br /> Pit or Grout Inspection byDate Final Inspection by ate17,1-,�T <br /> Additional Comments:-*.,`76 y _ <br /> ❑ Stk 466-6781 0 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 /> INFOFEE AMOUNT DU AMOUNT REMITTED CAS RECEIVED BY DATE PERMIT NO. <br /> a EH 13-241pEV. /x51 <br /> Eli 14-26 <br />