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APPLICATION FOR-PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT J <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 'I'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 City Lot Size pjy{ <br /> Owner's Name Address Phone <br /> 'Contractor Address a2 a License No. Phone ' <br /> TYPE OF WELL/ UMP: NEW WELL ❑ WELL REPLACEMENT © DESTRUCTION ❑ <br /> I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ lr� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP LINE ,; f <br /> s FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing } <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ' M Public f ❑ Other (1 Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation 1 -Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done D Type of Pump <br /> H. <br /> State Work Done <br /> Well Destruction ❑l Well Diameter Sealing Material (top 501 <br /> Depth { Filler Material (Below 50'1 ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION i I DESTRUCTIONkr(No septic system permitted if public sewer is <br /> ' N.,avaiiable within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other t <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: t iu <br /> Water table depth- <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. LJa z" <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> FILTER BED e ❑ Distance to nearest: Well Foundation Property Line t? <br /> SEEPAGE PITS E I Depth = Size Number 9 <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line f <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 t <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the followin ` <br /> g: "I certify that in the performance of the work for which this permit is issued, E 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 applicant mu call o required spections. Complete drawing on reverse side. <br /> Signed <br /> µ Title: Data:' <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date Area <br /> Pit or Grout Inspectio Date Final Inspection by Date <br /> Additional Comments: <br /> El Stk 466-6781 ❑ Lod 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 I . <br /> { <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PEMIT'NO. <br /> �} Rr <br /> + EH 1 -241HEV,V/N5) <br /> EH 144-28 S✓\/, V�(6 S CJ. 4� <br /> V� ✓ G V UL..' <br />