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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON 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. 1 <br /> Job Address �� r City � Lot Size PM <br /> Owner's Name Address Phone <br /> V _ I <br /> Contractor - _—Address'4_ G� .` - License_No._�_Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> - PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ J\ 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 /> r <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 71 Public ❑ Other ❑ Delta Depth of Grout,Seal Type of Grout P <br /> I I Irrigation ..Approx. Depth I I Eastern --Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> ' a Y <br /> Well Destruction ❑ Weil Diameter Sealing Material {top 50'1 F <br /> Depth Filler Material (Below 501 __ I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION( I..,.DESTRUCTION, INo septic system permitted if public sewer is <br /> .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 ❑ Type/Mfg Capacity �' �� No, Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property line <br /> SEEPAGE PITS I I 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 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 applica t ust calf r all r fired inspec ns. Complete drawing on reverse side. <br /> Signed X Title:- o-c_. Data: j <br /> 'I <br /> FOR DEPARTMENT USE ONLY f <br /> y i <br /> Application Accepted by � • Data .y O Area <br /> Pit or Grout Inspection by Date Final <br /> � „ Inspection by Date <br /> fo U7 C CAdditional Comments: LXXG4 r <br /> ❑ Stk 466.6781 ❑Lodi 369-3621 ❑ Manteca 8234104 ❑ 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 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. <br /> 'y1l tl <br /> +.ER14-24IRtll.4iN51 t/ <br /> o <br />