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APPLICATION FOR PERMIT <br /> b <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTO[V, CA , <br /> ' Telephone (209) 466-6781 N� tau <br /> _ t PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) t� <br /> ��. <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 /> 3 �!(� Cit Lot Size PM <br /> Job Address q <br /> Address °+ - Phone ��.��r' <br /> Owner's Name +� , <br /> Contractor <br /> Address A �s License No. Phone <br /> TYPE OF WELL/PUM NEW WELL ❑ WELL REPLACEMENT ❑ -'DES bCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE= TO NEAREST_: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE � I <br /> FOUNDATION AGRICULTURE OTHER WELt PITS/SUMPS <br /> INTENDED USE TYPE OF WEL PROBLEM AR CONSTRUCTION SPECIFICATIONS ; <br /> EJ Industrial <br /> ❑ Open Bottom a a Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack r <br /> Type of Casing Specifications <br /> ta Depth of Grout Seal Type of Grout <br /> 17 Public 171 Other CI Del <br /> I I Irrigation <br /> -Approx epth I I Eastern Surface Seal Installed by �w <br /> Repair Work Done ❑ Type of mp H.P. State Work Done <br /> Materia op 50'1 <br /> Wall Destruction ❑ Well Diame Sealin� V <br /> Depth Filler Material fBelo 50'I - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l R PAIR/ADDITION l 1 DESTRUCTION. (No septic system permitted if public sewer is <br /> available within 200 feet. <br /> Installation will serve: Residence J_ _Commercial f Other n <br /> Number of living units: Number of bedrooms •�f <br /> Character of soil to a depth of 3 feet Water table depth <br /> Y <br /> Ca acit No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg <br /> Capacity- <br /> PKG. TREATMENT PLT. ❑ 11 Method of Disposal <br /> Distance to nearest: Well Foundation Property-Line , ,. ....d <br /> i Total length/size f <br /> LEACHING LINE ❑ No. & Length of lines / <br /> FILTER BED LI, DistanceIto nearest: Well t Foundation Property Line 1 <br /> it <br /> rl! <br /> SEEPAGE PITS I Depth Size Number _ <br /> :i <br /> SUMPS L-1 Distance'to nearest: Wel! Foundation Property Line �{ <br /> DISPOSAL PONDS ❑ i I <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 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 srgriatuie (� <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." I y ,_� <br /> The applicant must call for all required inspections. Complete drawing ono <br /> rsa side. �j p <br /> I <br /> Title: Date: <br /> Signed X <br /> t - <br /> IRTMENT USE ONLY <br /> r' Application Accepted by Date Area <br /> I Pit or Grout Inspection by <br /> Data Final Inspection by Date ?�i <br /> Additional Comments: ~ <br /> I] 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 /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> KSH RE IVED BY DATE, PERMIT NO. <br /> INFO <br /> +,EH 13-24(REV.i/H 5) 35 ' <br /> EH t4-ZB <br />