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- 4 <br /> APPLICATION FOR PERMIT <br /> j 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) 4= <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 /> Job Address a3 I ;, r <br /> Cit of Size PIM <br /> Owner's Name Address ° V . � "c / _ phone <br /> i <br /> Address License No. Phone <br /> TYPE OF WELL/PUMP: i' NEW WELL ElWELL REPLACEMENT 171DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ v <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 <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 r r Type of Grout <br /> ❑ Irrigation IlApprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> s _ <br /> Well Destruction ❑ Weff Diameter Sealing Material atop 501 <br /> Depth k;Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW` INSTALLATION 11 REPAIR PADDITION ❑ DESTRUCTION C1 (No septic system permitted if public sewer is <br /> X11 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: t <br /> Water table depth ' <br /> SEPTIC TANK ❑ Type/Mfg l Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> r <br /> Distance to nearest: i Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ .Distance to nearestA Well "Foundation Property line <br /> SEEPAGE PITS ❑ Depth f 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 r <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 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 applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X ! _ Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> 1 _ <br /> Application Accepted by i < j Date A Area <br /> Pit or Grout Inspection by _ ate Final Inspection by Date ^o" 7 <br /> Additional Comments: t <br /> ❑ Stk 466-6781 ❑ Lodi,, 369-3621 ❑ Manteca 823-7104 . ❑ Tracy. 835-6M. <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE <br /> r <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH! c RECEIVED <br /> /BY D�ATEq <br /> g7-PERRMIT/NCO. <br /> + EH 1324(REV.t i 8 51 �r ` ( /I/1y� Z f / ! <br /> EH 10.28 <br />