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APPLICATION.FOR PERMIT <br /> SAN JOAQUIN LOCAL.HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> E Telephone (209) 466-6781 <br /> PERMIT EXPIRES 7 YEAR FROM DATETISSUED <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. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. . <br /> f Job Address � � T ' <br /> City of Size <br /> Owner's Name <br /> Addre Phone <br /> r <br /> Contractor's Name Zns,"I Phone �' f <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENTt] DESTRUCTION ❑ <br /> IF <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial Iff Open Bottom ❑ Manteca. Dia..of,Well Excavation- — Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack i❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal t <br /> Type of Grout <br /> EJ Irrigation ---Approx. Depth ,r❑ Eastern Surface Seal installed by � <br /> Repair Work Done ❑ Type of Pump IH.P. _ State Workrpone <br /> .Well Destruction ❑ Well Diameter Sealing Material (top 501), 4. 4 f <br /> Depth i -04terial (Below 50'} <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ ITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) ' <br /> installation will serve: Residence .`Commercial— Others " t <br /> Numk"c -'-* x k .3 d y <br /> ber of living units:• Number of bedrooms_,• - (� <br /> Chitacter of soil to a depth of 3 feeii' Water table depth 4 <br /> SEPTIC TANK ❑ T g e/Mf 'f`* ... .s_ <br /> Capacity No. Compartments <br /> PKG. TREATMENT PLT. p 1i ! Method of Disposal. <br /> « Die-to nearest: Foundation <br /> Property Line <br /> Wt k <br /> LEACHING LINE. – � Total length/size <br /> ,W Nvr& Length of lines <br /> FILTER BED "❑` Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size 1 I = NNmber <br /> JL_ , - _ .. <br /> SUMPS Distance to nearest: Well Foundation Property n 12 Propy Line <br /> ry <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 erftify 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 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 must call f It required in tions. Com let rowing on r side. <br /> Signed XTitle: 1 � Date: <br /> OR DEPARTMENT USE ONLY <br /> p <br /> Application Accepted by <br /> W.AQAA AA Date 1 Area_ Q <br /> Pit or Grout Inspection by Date Final Inspection by _1n,�.�L_ ,_)1�~ Date <br /> Additional Comments: <br /> ❑ Stk- 466-6761 ❑ 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 AM <br /> INFO OUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE PERMIT"Np. <br /> + EH 13.241REV.10163( f, <br /> EH 14.26 Li—I O t <br /> �. <br />