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1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I <br /> 1601 E. HAZEL 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. <br /> Job Address +�/ D ll!"—K, o City Lot Size PM <br /> Owner's Name Address <br /> Addrr�es�s/ /t /� f Phone <br /> Contractor Address �C_ , / License N� l� � Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LJ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom I❑ Manteca Dia. of Well Excavation Dia. of Wel! Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation /�Approx. Dept { I�Eastern Su ace Seal Installed by _ <br /> Repair Work Dane Cie Type of Pump �� H.P. State Work Done <br /> f <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 a <br /> Depth Filler Material (Below 50 <br /> TYPE OF SEPTIC WORK:, NEW INSTALLATION i 1 REPAIRlADDITION l I DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other LA <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 /> i <br /> LEACHING LINE ❑ No. & Length of lines Total length/size ! <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line I <br /> i <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS ❑ Distance to nearest: Wel! Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that t 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 Di§trict. <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." Contractors 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 fo req red spections. Complete drawi .ng rev tse sid <br /> Signed X_ Title: � Date: <br /> F DEPARTMENT USE ONLY <br /> Application Accepted by Date Ar <br /> Pit Or Grout Inspection by Date Final Inspection by Data <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 359-3621 ❑ 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 95201FEE <br /> i <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N4. <br /> +.EH 13-24(REV.r/)15; <br /> EH 14.26 <br />