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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> i 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 NoASK for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address 3 S: } City C Lot Size �f d PM <br /> Owner's Name _ Address 04?1 ` e Phone � 43 <br /> Contractor Address 04,04 <br /> License N f 3 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK S R LINES DIS AL FLD. PROP. LINE <br /> FOUNDATION AGRIC TURE WELL THER WELL PITS/SUMPS <br /> f INTENDED USE TYPE OF WELL PROBLEM A?Di <br /> NST ION SPECIFICATIONS �} <br /> rf ❑ Industrial ❑ Open Bottom ❑ Manteca f Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracype o sing Specifications <br /> ❑ Public ❑ Other ❑ Deltapth of G t Seal Type of Grout <br /> ❑ Irrigation —Approx. Depth ,❑ East"nrface Seal I lied by <br /> Repair Work Done ❑ Type of Pump H. State Work Done <br /> Well Destruction ❑ Well Diameter ` Sealing Material Itop 50'1 <br /> qF , Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION No septic system permitted if public sewer is In <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> r 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 /> t <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well 7�ation Property Line <br /> ( LEACHING LINE ❑ No. & Length of lines Total length/size <br /> F FILTER BED ❑ Distance to nearest: Well F ndation Property Line <br /> r <br /> i <br /> SEEPAGE PITS ❑ DepthSize Number <br /> SUMPS ❑ Distance to nearest: e11 Foundation Property Line <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 /> j 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 applicant call for all req 'e ins tions. Complete drawing on reverse side. <br /> Signed Title: �� Date: <br /> FO DEPARTMENT USE ONLY <br /> Application Accepted by � Date �U� Area <br /> Pit or Grout,Inspection by Date Final Inspection by Date <br /> Additional Comments: w <br /> I ❑ Stk 466rMl ❑ 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 /> FEE AMOUNT DUE. AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> �Z�O'�7 6 /P7 <br /> + EH 13-24(REV.v/e 5) --t3 � <br /> EH 14-28 <br />