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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT No W <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. <br /> Job Address ���f Cti City Lot Size PM <br /> Owner's Name s Address /try !� o f� Phone �r z !1121 <br /> Contractor _Address License No, phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP iNST LATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES DISPOSAL FLD. P NE <br /> FOUNDATION GRICULTURE WELL OTHER WE PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AR ONSTRUCTIO FICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ype of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delt Depth of Grout Seal Type of Grout <br /> ❑ Irrigation _Approx' Depth astern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pum H.P. State Work Don <br /> Well Destruction ❑ Well eter Sealing Material Itop 561 <br /> pth Filler Material-jBelow 56 <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 T 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 ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <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. <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 licant mu call for ail required inspections. Complete drawing on reverse side. <br /> Signed X Cri Title: C) .A,Jv�4�\_ Date: <br /> DEPARTMENT USE ONLY <br /> Application Accepted by ..�CnJv./�h� Date Area <br /> Pit or Grout Inspection by Date Final Inspection by ! Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 3621 ❑ Manteca 104 ❑ Tracy 835 fi365 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE IN <br /> INFO AMOUNT DUE AMOUNT REMITTED K tASFr RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24(REV.1/9 510 <br /> EH 14-28 �` ♦. � t LS- .-.T <br />