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P I APPLICATION FOR PERMIT <br /> - SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 JM 2 0 L089 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> n i <br /> (Complete in Triplicate? E°�` �"� `�Il <br /> s � i' -i i�: �IBES <br /> Application is hereby made to the'San Joaquin Local Health District for a permit to construct and/of 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 /> Locale Health District. ., <br /> CityAZA. Lot Size PM <br /> Job Address <br /> Phone <br /> Owner's Name W Address <br /> N ! <br /> Contractor Address License No.d� 7 Phone <br /> TYPE OF WEL P: NEW WELL EJ WELL REPLACEMENT ❑ DESTRUCTION ElI�i <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 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �. <br /> ❑industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. 01 Well Casing <br /> ❑ Domestic/Private LJGfavel Pack ❑ Tracy Type of Casing Specifications <br /> M Public Cl Other f.] Delta Depth of Grout Seal Type of Grout <br /> Irrigation JMAppro.x, Depth I 1 Eastern Surface Seal installed by - <br /> C� Typel of Pum �"" H.P. - State Work Done <br /> Repair Work Done w= P <br /> gob <br /> Well Destruction ❑ Welll�Diameter Sealing Material Itop 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION 1.1 DESTRUCTION l 1 (No septic system permitted if public sewer is <br /> available within 200 feet.) <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. ❑ <br /> i Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> I� <br /> LEACHING LINE ❑ Total lenthisize No. & Length of lines g <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> '" Number <br /> SEEPAGE PITS l I Depth Size <br /> SUMPS Cl `Distance to nearest Well Foundation Property Line <br /> DISPOSAL PONDS ❑ �I <br /> -hereby-certify that I have prepared this application arid'that the work will !}e done i�accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health Di§trict. <br /> Home owner or licensed agents 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." 1 <br /> The applicant must call f Il;required inspections. Complete drawing on reverse side. <br /> Signed X Title: <br /> Date. <br /> :I1 <br /> FOR DEPARTMENT US ONLY- 61 <br /> 11 <br /> Application Accepted by 10. <br /> Date Area <br /> II Pit or Grout Inspection by Date Final Inspection by Date N <br /> —417 <br />! Additional Comments. <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies tFo: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMa11U AMOUNT REMITTED CASH CK 9 RECEIVED BY DATE PERMIT'NO. <br />{ INFO 1 <br /> ♦.EH 13-24 IREV.f/H 5) <br /> EH 14-2e <br />