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f„ PPLICATION FOR PERMIT <br /> SAN JOAO.UIN_LOCAIL HEALTH DISTRICT <br /> s 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> 1PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> b / I IComplete in Triplicate) s <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 /> �f <br /> Job Address i41 Lot Size PM <br /> Owner's Name Address Phone t <br /> FA> <br /> Contractor Address IT <br /> License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ "i \ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing \� . <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by E <br /> Repair Work Done ❑ Type of Pump t H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Seating Material It 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is <br /> � available within Z00 feet.) i <br /> Installation will serve: Residence v 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 .B--Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 171e Method of Disposal <br /> Distance to nearest: Well Foundation Property tine 1 <br /> LEACHING LINE No. & Length of lines S ___ To_tal length/size 0 r <br /> FILTER BED El Distance to nearest: Well, Foundation Property Line <br /> SEEPAGE PITS /PC Depth Size 3 �J Number <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. <br /> Home owner or licensed agent's signature certifies the following: "I certify that,in the perfdrmance.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 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. 4 ; <br /> The applicant must call for all required inspections Complete drawing on'reverse side. <br /> t <br /> Signed Title: 1 Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> I <br /> Pit or Grout Inspection by Date Final Inspection by 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 201)9, Stk.;CA•95201FEE <br /> 1 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-241REV.i/as) <br /> EH 1426 <br />