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APPLICATION,FOR PERMIT <br /> SAN JOAQUIN.LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <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 /> Job Address City Lot Size_Z � PM <br /> k <br /> Owner's Name - Z Address _ - _ Phone <br /> Contractor Address License No. Phone <br /> /.,TYPE OF WELL/PUMP: WELL 13 WELL REPLACEMENT Elri.. DESTRUCTION ❑ <br /> + t ,' PUMP INSTALLATION ❑ SYSTEM REPAIR LD OTHER El <br /> I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL x PITS/SUMPS <br /> INTENDED USE ,,� TYPE OF WELL' PROBLEM AREA CONSTRUCTION SPECIFICATIONS � <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia�ofWe I-Casing <br /> ❑ <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specification's <br /> I ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material IBelow 501 <br /> i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within et.� s <br /> y i a <br /> Install1ation will serve: Residen e_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> j: Character of soil to a de�hof feet:, + Water table depth [1� <br /> SEPTIC?TANK ❑ Type/Mfg Capacity No. Compartments? 1 <br /> i t <br /> PKG. TREATMENT PLT. ❑ I Method Disposal <br /> Distance to nearest: Well Foundation'- Property Line v <br /> LEACHING"LINED- �6�N6. & Length of lines C9 Tota! lengthlsize <br /> FILTER BED ❑k Distance to nearest: Well Foundation Property Line <br /> VEE�AGE PITS X� Depth z Size Number 2 <br /> C37- <br /> UMPS f ❑ Distance to nearest: Well d Foundation Property Line <br /> r / I DISPOSAL PONDS ❑ � <br /> 1 J I hereby.certify'thai-l-havepr ared 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 /> er>ploy any person in'§uch manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature <br /> 6 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 Califo Ia.' <br /> The applicant ust all fo all requir inspections. Complete drawing on reverse sidle. -f y <br /> I <br /> f <br /> Signed X /Title: �Datei <br /> FOR DEPART T USE ONLY �. <br /> v © <br /> Application Accepted <br /> r Date /' Area — <br /> Pit or Grout Inspection-by - ate Final Inspection by Date ` <br /> + Additional Comments: <br /> ❑ Stk 466-6781 1.•❑ 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 /> I <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. <br /> INFO <br /> a EH 13-24 MEV., <br /> EH 1426 <br />