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0 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 /> T �C (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 applicat}on is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address City Lot Size PM <br /> Owner's Name l Address Phone <br /> �1 1— — <br /> Contractor. C Address 19 �r�f' License no Phone 7 } <br /> i <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION 11 1 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR )-Z- OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS w <br /> IA Industrial IJ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 5�,DomesticlPrivate Li Gravel Pack ❑ Tracy Type of Casing Specifications <br /> FI Public (.l Other Cl Delta Depth of Grout Seal __ Type of Grout <br /> I I Irrigation -_—.Approx. Depth nni I Eastern Su ace Sual Installed by --- <br /> Repair Work Done Type of Pump �.dy,> H.P. ! State Work Done <br /> Well Destruction © Well Diameter Sealing Material [top 50'i �} <br /> ti <br /> Depth Filler Material (Below 501 -- -- 4 <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION I i (No septic system permitted if public sewer is <br /> available within 200 feet.) S <br /> Installation will serve: Residence Commercial_ Other y q <br /> Number of living units: Number of bedrooms �J <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 Ll No. & Length of lines Total length/size _ <br /> FILTER BED 0 Distance to nearest: Well Foundation — Property Line <br /> SEEPAGE PITS I I Depth Size _ Number i <br /> SUMPS I I Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS [.7 <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 p y an y person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature i <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 app st call for all requir�ispec�fio . m to drawing on rev side. <br /> Signed X Title: fly¢ Date: ? <br /> FDS hiTMENT USE ONLY _ <br /> Application Accepted bye Date " Area <br /> i <br /> Pit or Grout Inspection by Date— Final Inspection by Date <br /> Additional Comments; <br /> ❑ Sik 466.6781 ❑ Lodi 368-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 <br /> I <br /> iFEEO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMITND. <br /> , EH 13-24IREV.I/H51 <br /> EH 14.26 <br /> I <br />