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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 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 /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. /� L <br /> Job Address +� City Lot Size PM <br /> Owner's Name F Address. Phone <br /> kt) <br /> Contractor AZY Address License No. Phone_ <br /> /TYPE OF WELL/PUMP:. -.NEW WELL?❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION"❑ q .-y SYSTEM REPAIR.❑ ,,.,� OTHER ❑ <br /> ti <br /> DISTANCE TO NEAREST: SEPTIC TANK r SEWER LINES DISPOSAL:-FCD.-'—---PROP. LINE <br /> FOUNDATION-\V - .AGRICULTUREWELL � OTHER WELL PITS/SUMPS <br /> i <br /> INTENDED USE TYPE OF WELL t� 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 /> 11 Public F] Other " ❑ Delta Depth of Grout Seal Type of Grout _ l <br /> i Irrigation Approx. Depth` I I Eastern Surface Seal Installed by - 4" <br /> r <br /> Repair Work Done ❑ Type.bf,Pump H.P. State Work Done <br /> `Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITIO DESTRUCTION l I Wo septic system permitted it public sewer is ' <br /> available within 200 feet.) <br /> Installation will serve: Residenc= Commercral Other - <br /> Number of living units: Number of droom�_3 Af <br /> Character of soil to a depth of 3 feet: /fib � ` �. Water table depth <br /> SEPTIC TANK ❑ Type/Mfg µ j ' Capacity - No. Compartments <br /> PKG. TREATMENT PLT. 0 "" ti..� Method of Disposal <br /> Distance to nearest: Well foundation Property Line <br /> LEACHING LINE r <br /> Z. & Length of lines Total length/size "-" <br /> FILTER BED -❑ Distance to nearest: Well •M Foundation Property Line <br /> SEEPAGE PITS l I Depth Size Q Number <br /> 5 i Distance to nearest: Well Foundation Property Line <br /> UrSPOSAL PONDS Cl <br /> I hereby certify'thar 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 of 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 applicant must call for req u'a rnspec' Complete drawing on reverse side. <br /> Signed X r Title: Date: <br /> F DEPARTMENT USE ONLY <br /> Application Accepted by Date Area / <br /> Pit or Grout Inspection by Date Final Inspection by Date .! 7 <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 /> CK <br /> se. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> \ ♦ EH1 (,24(REV. �� <br /> 4- Vv 111y(l�^ - 3 <br />