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APPLICATION FOR PERMIT , <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ?CSV',-� 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> V 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 � L <br /> City GC./�J�---�bt Size PM <br /> Owner's Name d <br /> Address Phone <br /> Contractor Address' 6 <br /> TYPE OF WELL/PUMP: License No D Phone lt`� <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION il❑ SYSTEM REPAIR,�r OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS PITS/SUMPS <br /> ❑ Industrial ❑ Open Bottom Manteca Dia, of Well Excavation <br /> Domestic/Private ❑ Gravel PackDia. of Well Casing <br /> ❑ Tracy Type of Casing ' <br /> ❑ Public ❑ Other ❑ Delta Specifications <br /> Depth of Grout Sea] ype of Grout <br /> ❑ Irrigation __ Approx. Depth .© Eastern SLyface Seal Ins6lled'4y <br /> Repair Work Done ,K Type of Pump C H,p. <br /> Well Destruction EJ Well Diameter ~ , State Work' one <br /> Sealing Material (top 50') <br /> Depth 'Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ : DESTRUCTION ❑ (No septic system permitte i public sewer is <br /> Installation will serve: Residence Commercial Other available within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANKWater table depth <br /> ❑ Type/Mfg <br /> PKG. TREATMENT PLT. C1Capacity No. Compartments <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BEDTotal length/size i <br /> ❑ Distance to nearest: Well Foundationi <br /> Property Line � <br /> I <br /> SEEPAGE PITS ❑ Depth Size <br /> Number <br /> SUMPS I <br /> ❑ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ Property Line <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 applic m t call for all requ" d ins ions. C plate drawing on reverse side. . - <br /> Signed <br /> Title: <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date '� z <br /> Pit or Grout Inspection b Date {, <br /> Final Inspection by Date <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 /> FEE AMOUNT DUE AMOUNT REMITTED CK# <br /> INFO CASH RECEIVED BY DATE PERMIT NO. <br /> � � <br /> :H13-24[FEV.1/H51 - <br />