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I <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I <br /> 1691 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is he+eby 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 Nn. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> I <br /> 7 �+ / 46 <br /> Job Address <br /> L,,? 0 � � � �� �if.l ` City Lat Size PM <br /> Owner's Name � <br /> Address ! Phone <br /> i <br /> Contractor ss Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER-LINES DISPOSAL FLO. PROP. LINE <br /> FO DATION AGRICULTURE WELL OTHER WELL PITS/ 7 PS <br /> INTENDED USE TYPE 0 PROBLEM AREA CONSTRUCTION SPECIFICATIONS '! <br /> ❑ Industrial ❑ Open Bottom Dia. of Well Excava Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy 9ZIUL11.9 : Specifications <br /> {-1 Public _ Delta Depth of Grout Sea Type of Grout <br /> E 1 Irrigation _..Approx. Depth l 1 Eastern Surface Seal installed by- <br /> Repair <br /> y Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 5019 <br /> Depth Filler Material (Below 501 Q t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION (No septicjjsystem permitted if public sewer is <br /> ' 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: 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 Lin, <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> it <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. jI <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, 1 shall nol <br /> employ any person in such rrner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following:"I cert' 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 Calif ia." <br /> i <br /> The applicant ust` all require4 inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> QR DEPARTMENT USE ONLY <br /> Application Accepted by ice" Date Area <br /> rII - _ <br /> Pit or Grout Inspection by ate Final Inspection byi��cte 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 /> ! <br /> FEE <br /> ! <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY GATE PERMIT'NO. <br /> +. 11 <br /> EH 13-24(REV.Iiks! _ ��. �.s ��(� <br /> EH 11-2e ,J <br /> �i <br />