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, <br />} <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT t <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> 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. Al <br /> Job Address City A of Size PM <br /> Owner's Nam 1��" t Address n' Phone <br /> Contractor Address~ License No. Phone <br /> .TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> S <br /> PUMP INSTALLATION SYSTEM EPAIR ❑ OTHER 1-1DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> i FOUNDATION GRICULTURE LL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM EA NSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Botiom Cl Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T <br />� ype of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta th of Grout Seal Type of Grout <br /> ❑ Irrigation �pprox; Depth ❑ Eastern Su Seal Installed by <br /> Ilr Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing-Material ftop 50'i <br /> Depth Filler Material Melow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION INo septic system permitted if public sewer is �f <br /> } available within 200 f et.I <br /> Installation will serve: Residence. I Commercial, Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:1 .Water table depth <br /> SEPTIC TANK ❑ Type%Mfg - ranarav No. Compartments <br /> PKG. TREATMENT PLT. ❑ s t Method of Disposal <br /> Distance to nearest: Well ound ion Property Line <br /> LEACHING LINE ❑ No. & Length of lines X Total length/size <br /> FILTER BED ❑ Distance to nearest: ;Well /oation Property Line <br /> SEEPAGE PITS ❑ Depth 1 Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ I Y <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 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 t . 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 /> licant must call f r all required ' spe lions. Complete drawing an reverse side. <br /> i <br /> Signed Title: Date: <br /> i FOR DEPARTMENT USE ONLY <br /> Application Accepted by l `^ - Date —� Area <br /> Pit or Grout Inspection Date Final Inspection by Date <br /> Additional Comm /ents: 0 �r !kit <br /> ❑ Stk 466-6781 ❑ Lodi 3&3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 5.0 f,{J <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9=11 --obFEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. <br /> + EH13-24 IAEV.t/951 <br /> EH 1426 <br /> t <br />