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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <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. 1662 for weii/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address City Lot Size PM <br /> Name AddresSf' Phone <br /> i <br /> Owner's - <br /> Ir <br /> I Contractor Address ai License Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. <br /> 13 1 <br /> FOUNDATION—__ACR_fCl)LTURE WELL OT" PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONST N SPECIFICATIONS <br /> t ❑ Industrial ❑ Open Bottom ❑ Manteca __-Era_. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private 171 Gravel Pack ❑ Tr Type of Casing Specifications - t <br /> (`l Public El Other Delta Depth of Grout Seal Type of Grout v <br /> ! 1 Irrigation -Ap epth 1 1 Eastern Surface Seal installed by <br /> Repair Work Done ❑ e of Pump H.P. State Work Done_ <br /> Well Destructio Well Diameter Sealing,Materia! (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION i I""'DESTRUCTION ( o septic system permitted if public sewer is <br /> 4 1 available within 200 feet.) t� <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 /> k SEPTIC TANK ❑ Type/r1 fg Capacity No. Compartments <br /> k PKG. TREATMENT PLT. ❑ ' ti' _ Method of Disposal <br /> CDistance to nearest: WellFoundation Property-Line <br /> . <br /> r, LEACHING LINE ❑ No. & Length of lines-- Total length/size <br /> FILTER BED ❑ Distance to nearest:/ Well I Foundation rt_ Property Line <br /> 1 SEEPAGE PITS l 1 Depth f 4 Size Number <br /> I SUMPS D Distance to nearest: Weil 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 /> 1 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 /> F 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. n <br /> The applica m st call for all re Wed inspections. Complete drawing on ayerse,.side. Q� <br /> Signed Title: <br /> d Date: v <br /> F ARTMENT USE ONLY Q� <br /> o- Application Accepted by Date v Area <br /> Pit or Grout Inspection by Date Final Inspection by 6 _ Date <br /> Additional Comments: <br /> f ❑ Stk 466-6781 ❑ Lodi 69-3621 ❑ 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 /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO Cp{ASH <br /> +.EH13-24(REV.t/H5) ��.00 J CJ .1-71-71�I <br /> EH 14-M- <br />