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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> M Telephone {209) 466-6781 <br /> i <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 isf <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 <br /> 1 City pD Lot Size . PM. u• <br /> Owner's Name /V Address <br /> f - A Phone } <br /> Contractor's Name �,e License No. %3 <br /> TYPE OF WELL/PUMP: Phone <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK}' �SEWER'CINES ' . - <br /> DISPOS 41 FLD. <br /> + PROP. LINEu-= - –_ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �u <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Q Industria! ❑ Open Bottom ❑ Manteca Dia, of Well Excavation <br /> �[Domestic/Private Q Gravel Pack ❑ Tracy T Dia. of Casing <br /> Type of Casing Specificaatiolio ns <br /> Q Public ❑ Other ❑ Delta Depth of Grout Seal <br /> ❑ Irrigation --Approx. Depth Type of Grout <br /> I Surface Sea! Installed by <br /> Repair Work Done ❑ Type of Pump H.P. <br /> Well Destruction ❑ Well DiameterState Work Dane <br /> Sealing Material (top 50') """' <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION El REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted it public sewer is <br /> Installation w e: available within 200 feet.) <br /> Residence <br /> Commercial—s.Other <br /> Number of living units: Number bf bedrooms <br /> Character of soil to a depth of 3 e I <br /> SEPTIC TANK - Water table depth <br /> ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Eli <br /> Method of Disposal f <br /> Distance to nearest: Well Fou nProperty Line <br /> I � <br /> LEACHING LINE Q No. & Length of lines <br /> FILTER BEDTotal a size <br /> ❑ Distance to nearest: Well Foundation Property <br /> SEEPAGE PITS ❑ Depth. p Size Number <br /> ❑ Distance to nearest: Well Foundation � - - <br /> DISPOSAL PONDS ❑. t y fProperty`Li`ne <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 <br /> rules anti regulations of the San Joaquin Local Health District. <br /> Home o>jirner or licensed agent's signature ceFtifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any penton 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." J, <br /> The applicant t all r all r fired ins ctio . Cc plate drawing on rev <br /> Signed Title: <br /> :-' Date: zs <br /> FOR D PART ENT USE ONLY <br /> Application Accepted by C _ <br /> Pit or Grout Inspection by Date Final Inspection Data Ar by 7 c <br /> Date <br /> Additional Comments: <br /> Cl 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. Box2009, Stk., CA 95201 <br /> 1 <br /> FEE AMOUNT DUE t AMOUNT REMITTED CK <br /> INFO gg CASH RECEIVED BY DATE PERMIT'NO. <br /> + ER 13-24 IREV.10183) <br /> EH 1428 <br />