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APPLICATION.FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTR CT <br /> 1601 E. HAZELTON AVE.,.STOCKTON, <br /> Telephone (209) 466-6781 ; <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISS D <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 describeThis ication is <br /> d. <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regula„i 4 t e San Joaquin <br /> Local Health District. -. S <br /> -tot Size PM <br /> City <br /> Job Address _ � - / J ' <br /> Phone <br /> Owner's Name' �" !�V Address <br /> License No. Phone <br /> Contractor <br /> Address <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ElSYSTEM REPAIR ❑ OTHER El <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> WER LINES DISP FLD. PROP. LINE <br /> FOUNDATION AG <br /> ,ULT <br /> WELL HER WELL P1TS15UMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONS ION SPEGIFiCATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca <br /> Of Well Excavation Dia. of Well Casing <br /> ''-of.Casing Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Grout <br /> ❑ Public ❑ Other ❑ D y Dept f Grout Seal yp <br /> ❑ Irrigation �pprox Depth Eastern `/:Surface, eal it <br /> by <br />+ H.,P 1 State Work Done <br />€, Repair Work Done ❑ Type of Pump _-_ <br /> ff Well Destruction ❑ Well Diameter ~.Sealing Material (top 50'1 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ <br /> REPAIR/ADDITION ❑ IDESTfl TIO aNOdabPe�wi hsn 20D tem feetitted if public sewer is <br /> S <br /> Installation will serve: Residence�� Commercial Other <br /> f Number of living units: Number of bedrooms Water table depth <br /> ff Character of soil to a depth of 3 feet No. Compartments <br /> 4! Cap ity <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal; <br /> � PKG. TREATMENT PLT. ❑ � <br /> �_� <br /> Distance to nearest: Well Foundatio11 n' Property Line <br /> 1: <br /> LEACHING LINE EJNo- & Length of lines Total length/size <br /> w, f <br /> FILTER BED ElDistance to nearest: Well Foundation Property Line} <br /> i SEEPAGE PITS ❑ Depth Number <br /> Size } <br /> e to nearest: Well Foundation Property Line <br /> ❑ Distance F SUMPS � <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 /> is rules and regulations of the San Joaquin Local Health District. `: `' i N <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 asto 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 w Tk for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." FI. 5„ <br /> The applicant mus call for all required inspections. Complete drawing °n reverse side. f <br /> • �, ,/Title: , Date: <br /> Signed X _ <br /> R DEPARTM T USE ONLY � o <br /> Date Area {y <br /> F Application Accepted by17_ + <br /> Date Final Irispecfion'tiy�. Date <br /> Pit or Grout Inspection by j <br /> k Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369,3621 L1 Mani 823.7104 1-1 Tracy 835-6M5 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> t <br /> K "'RECEIVED BY ` DATE PERWTr NO.F - <br /> FEE •. —_AMOUNT DUE• �--AMOUNT REMITTED � ^�C <br /> 4 .. r. ...� -INFO 3'3 <br /> r + EH 1324(REV. /x51 �,`, 9.�� eti„ •.7 -,-- _,. <br /> F EH 1426 _ <br />