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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 f the San Joaquin <br /> L cal Health District. <br /> Job Address <br /> City Lot Size69X PM <br /> Address <br /> Phone <br /> Owner's Name <br /> 4 7 <br /> Fa <br /> Contractor Address �C Licensee No Phone <br /> �� <br /> TYPE OF WELLIPUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. `PF�OP.,LI�- N�E <br /> FOUNDATION AGRICULTURE WELLELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL "' PIF OBLEM AREA'S'C CTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ( ❑ Mant Dia- of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack Tracy Type face <br /> Casing Specifications <br /> F Public Other fl Delta Depth of Graut Seal Type of Grout _ <br /> I Irrigation _..Approxi Depth e 4 I Eastern Surface Seal Installed by - <br /> Repair Work D ❑ Type of Pump H.P- State Work Done i <br /> Sealing Material (top 50'1 1 <br /> WeII ruction ❑ Well Diameter k 9 <br /> Depth " '" ' Filler Materi6i,1B"slow 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION ! I DESTRUCTID No septic system permitted if public sewer is ( J� <br /> t, available within 200 feet.) v <br /> installation will serve: Residence Commercial_ Other'l <br /> Number of living units: Nurriber of bedrooms ' z <br /> I Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O r Type/Mfg Capacity No. Compartments y`7 <br /> PKG. TREATMENT PLT. 1:1k a Method of Disposal <br /> Distance to nearest.` i'Well FOundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines {. F' Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> E y ; <br /> SEEPAGE PITS l I Depth Size Number <br /> Vf <br /> SUMPS ' L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ A. k <br /> I _ <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 /> "I certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: <br /> compensation laws ss California." Contractors hiringec sub-contracting signature <br /> employ any person in such manner as to become subject to workman's co <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." t <br /> The applicant must call for all requ'ed inspect( s. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> r �FOR DI= TMENT USE ONLY <br /> I -,[I- Area t 0 <br /> Application Accepted by Date <br /> I b-` Pit or Grout Inspection by Date Final Inspection by Dateff <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED ASH;:::: RECEIVED BY DATE PERMIT'NO. <br /> (NFO <br /> ♦.EH 13-24/HEV.t i n 51 <br /> EH 14-28 <br />