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APPLICATION FOR PERMIT <br /> i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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 �j ` �J�t _-City Lot Size_ PM <br /> Owner's Name <br /> one <br /> Contractoress V License No. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑. WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD., PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> _- Dia. of Well Casing <br /> ❑ Domestic/Private °'"- ❑ Gravel Pack ❑ Tracy Type of Casing Specifications' <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ <br /> i I Irrigalion =-Approx. Depth v I i Eastern - Surface Seal Installed by <br /> Repair Work Done ❑ Type of PumpH.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material itop 50') <br /> Depth P '� Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION I i (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ 'Commercial— Other t - <br /> Number of living units: Number of bedrooms t <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> 4 PKG. TREATMENT PLT. ❑ t v 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 1 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 1 <br /> rules and regulations of the San Joaquin Local Health District. <br /> 4 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 issuedr I shall employ persons subject to workman's compensa- <br /> tion laws of California. <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: <br /> Date: <br /> r FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date Area <br /> Pit or Grout Inspection by Date Final Inspection <br /> Date <br /> Additional Comments: d L <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 MJhteca 823-7104 ❑ Tracy 835-6385 I <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 <br /> INFO CASH RECEIVED 6Y DATE PERMIT*NO. <br /> +.EM 13-24{REV,1/e 51 , <br /> EH 14-28 <br />