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APPLICATION FOR PERMIT <br /> SAN JOAQU1N'LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA j <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. <br /> e <br /> Job Address 0 t e e CityC — Lot Size PM i <br /> Owner's Name reeAl ® '^ —Address i d p r� _ — Phone <br /> Contractor a Address License N __ Z Phon <br /> TYPE OF WELL/PUMP: t NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO:USE <br /> SEPTIC TANK SEWER LINES OSAL FLD. PROP. LINE _ <br /> FO TION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED TYPE OF WELL OBLEM AREA CPNSfRUCTION SPECIFICATIONS <br /> Ll Industrial ❑ Open Bottom ❑ Man Dia. of Well Excavation Dia. of Well Casing <br /> O Domestic/Private ❑ Gravel Pack ❑ Tr Casing Specifications <br /> ❑ Public ❑ Other" Delta Depth.of Grou Type of Grout ,. <br /> ❑ Irrigation �pprox pth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Typ ump ` H.P. State Work Done s <br /> Well Destruction ❑ ell Diameter Sealing Material (top 501 <br /> Depth t Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> k I S available within 200 feet.) <br /> Installation will serve: Residence 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 X Type/Mfg Capacity No. Compartments <br /> Ar <br /> PKG. TREATMENT PLT."❑ € t Method of Disposal <br /> ' Distance to nearest: Well Foundation Property Line__. <br /> LEACHING UNE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation F Property Line <br /> I P <br /> J i <br /> SEEPAGE PITS ❑ Depth Size 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 performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subjecttoworkman'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 /> F The applicant must call fo all require inspections. Complete drawing on reverse side <br /> Signed * Title: —e�� Date: 42 <br /> FOR DEPARTMENT USE ONLYQl� <br /> Qn <br /> Application Accepted by 0^ Date v l— Area <br /> Grout-Inspection `�- '•' -` """'"Date'''�. Date Final Inspection by` <br /> Additional Comments: ^`�Q <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ anteca 823- 104 ❑ 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 RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> I + EH 13-241REV. <br /> EH 14-26 `--C✓ _ <br />