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m APPLICATION FOR PERMIT <br /> s 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 iSan 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 /> City Lot Size PM <br /> Job Address <br /> ,� �p # <br /> Owner's Name <br /> I� Address _ Phone <br /> Contractor <br /> Address License IVa. Phone_ <br /> TYPE OF WELL/PUMP: �I: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION [ — <br /> PUMP,INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1� <br /> INTEND SE TYPE-OF-,WELL PROBLEMAREA CONSTRUCTION.SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca D ia.of"Well Excavation Dia. of Well Casing {„ <br /> mesticlPrivate ❑ ra arJ Tra _ �..- TKPe;of Casing Specifications v 1 <br /> Fl Public M Other Delta�_ Depth of Grout Seal-_. Type of Grout <br /> I I Irrigation Appro pth ! I Eastern _ rfaca Seal Installed by <br /> Repair Work Done ❑ Ty Pump H.P._ <br /> ~ State Work Done 4 <br /> Well Destruction Well Diameter Sealing Material atop 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION t 1 DESTRUCTION Mo septic system permitted if public sewer is <br /> IINiVilable within 200 feet.M <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 /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ II Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> IM <br /> LEACHING LINE ❑ Ngo. & Length of lines Total length/size <br /> r <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> Ip' <br /> Number <br /> SEEPAGE PITS I 1 Depth Size <br /> SUMPS Ll Distance to nearest: Well 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 /> 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,t shall employ persons subject to workman's compensa- <br /> tion laws of California." 1I' <br /> The applicant must call for all required inspections. Complete drawing on averse side. <br /> Signed X I Title: Date: <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> � � <br /> Application Accepted by - Data 7Area <br /> i� Date Final Inspection by Date <br /> Pit or Grout Inspection <br /> Additional Comments: <br /> ID 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 2003, Stk., CA 95201 <br /> I� <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED i3Y DATE PERMIT'NO. <br /> INFO <br /> +.EH13-241REV.IiHSf IS'[�Kl Imo' 117 l� �a �y57 <br /> EH 14-28 EEE <br />