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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL.HEALTH DISTRICT <br /> 1601 E. HAZE T ON 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. <br /> i I <br /> t s �c t as <br /> Job Address � Cit�L>.d>r' Lot Size` PM <br /> Owner's Name Address l Phone <br /> a, ? �g s� <br /> Contract Address . n License No. z� Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ f <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 t <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing I <br /> ❑ Domestic I Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> (`I Public (7 Other Cl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation --Approx. Depth l I Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material.ltop-.501-- -- <br /> Depth (ler Material (Below 50') -- <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I REPAIR ADDITION DESTRUCTION.l I (No septic system permitted if public sewer is <br /> 'available within 200 feet.) <br /> 45 <br /> M - - --- _ <br /> installation will serve: Residence_ Commercial— Other <br /> Number of living units:c Number b dr ms d <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Type/MfgCapacity�p .�— No. Gompartments <br /> PKG. TREATMENT PLT. (-1 f Method of Disposal I <br /> Distance to nearest: Well Foundation /� Property Line is <br /> {' t f <br /> LEACHING LINE No. & Length of.lines - _ Total length/size- <br /> FILTER <br /> ength/size FILTER BED ❑ Distance to ne ra est: Well Foundation _._._.�.Q_ Property Line_ -� <br /> l <br /> SEEPAGE PITS Depth Sizeom; `` f�umber <br /> SUMPS Ll Distance to nearest: Well tFoundation Property <br /> DISPOSAL PONDS ❑ F r <br /> hereby certify that I have prepared this application and that the work will be done in accordance with an Joaquin county ordinances, state laws, an <br /> rules and regulations of the San Joaquin Local Health Di-strict.,�- <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 no <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 perfofmance of the workt for�which this permit is issued,I shat!eniploy'persons subject to workman's compensa- <br /> tion laws of California." -..6l , . r'-- - <br /> =are' <br /> JThe applic tust call fred inspections. Complete drawing on reverse side. n a �� <br /> 1511` <br /> Signed X Title: l r Date: <br /> F. R DEPARTM T USE ONLY <br /> Application Accepted by, Date 1 Area <br /> s.: - Imo, <br /> Pit or Grout Inspection by �- ~ ;Date Final Inspection by >' Date <br /> Date �D <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., GA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY '`DATE PERMIT NO. <br /> INFO <br /> a EH 13-24(REV.]/A 51dWCL I <br />' EH 14-26 f 1 L <br />