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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephohe (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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 /> G City S � Lot Size PM <br /> Job Address � ` <br /> �d &A L ������ Phone <br /> Owner's flame <br /> Address zr <br /> .Od V /yG`CA;N< dVs/ License No. Phone <br /> Contractor Address O N <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ <br /> '�- SYSTEM REPAIR -' OTHER ❑ Jn PUMP-INSTACLATION_ET ��DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDISPOSAL FLD. PROFOUNDATION AGRICULTURE WELL OTHER WELL PI7INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �Dia..oIndustrial Open Bottom ❑ Manteca Dia. of Wekl Excavation Specif❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> Other ❑ Delta Depth of Grout Seal Type - <br /> F'1 Public _t�b_A rox, Depthl I Eastern Surface Seal Installed byI I Irrigation 3_ UP D ,,.sf4�Repair Work Done Type of Pump La Y�"'{ H.P. State Work DoneWell Destruction ❑ Well Diameter 1� f Sealing Material (top50'1 <br /> Depth t Filler Material (Below 50')TYPE OF SEP TIC WORK: NEW INSTALLATION I.1 REPAIR/ADDITION f I DESTRUCTION E I 'availabetrwthin 200 fec system c sewer is <br /> Installation will serve: Residence— Commercial, Other <br /> t Number of living units: Number of bedrooms <br /> ~ Water table depth <br /> Character of soil to a depth of 3 feet: <br /> Capacity , No. Compartments <br /> SEPTIC TANK L1 Type/Mfg <br /> Method of Disposal <br /> PKG. TREATMENT PLT. <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE LI No. & Length of lines Total length Property <br /> tiner <br /> FILTER BED ❑ Distance to nearest: Well Foundation "Propeerly <br /> i <br /> h Size Number <br /> SEEPAGE PITS l I` Dept <br /> SUMPS Cl Distance to nearest: Well <br /> Foundation Property tine <br /> DISPOSAL PONDS ❑ � �. ` <br /> 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 Sari Joaquin'Local.Health Di3trict. <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 /> a employ any person in such to become subject to workman's compensation laws of California."-Contractor's hiring or sub_contracting signature <br /> certifies the following: "1 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 for all required inspections. Complete drawing on reverse side. <br /> I Signed X_-��l Title: /1EOPr6 �1 p"`'r y/ /� h• Date: J <br /> FOR DEPARTMENT USE ONLY r <br /> Dates E Area <br /> Application Accepted by <br /> Pit or Grout Inspection y <br /> pate Final Inspection by Date �y <br /> i <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-5385 <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 ASH RECEIVED BY DATEPERMITjNO <br /> INFO <br /> +.EH 13-21(REV. /H 5) <br /> EH t4-28 <br /> t <br />