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No <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL:HEALTH DISTRICT 1 <br /> 1601 E. HAZELTON AVE.,_STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED' <br /> (Complete in Triplicate) <br /> t an /or install the work <br /> Application is hereby made <br /> a toJhaqSan Joaquin u n County OrdinalHealth nce No.District49 for sewage or it Ii 1862 forcatiOn is <br /> to cweilapump and the Rules and(Regulations of he San l Joaquin <br /> made in compliance with fu 1 <br /> Local Health Distr Act. + ' , <br /> City <br /> Lot Size PM <br /> Job Address I I ` <br /> Address <br /> Phone <br /> Owner's Name <br /> Address�C� <br /> ;! r .cam _ License No._Phone_ <br /> Contractor�— DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL-REPLACEMENT�3 <br /> PUMP INSTALLATION ❑ <br /> ' �$YSTEIVI REPAIR d OTHER ❑ <br /> SEWER LINES _ DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL "PROBLEM AREA CON STRUCTION'SPECIFICATIONS Dia. of Well Casing <br /> El Industrial <br /> C] Open Bottom ❑'Manteca Dia. of Well Excavation ° <br /> S <br /> Type of Casing l Specifications <br /> 'r 1.4 <br /> ❑ Domestic/Private d Gravel Pack ❑ Tracy Depth of Grout Seal i Type of Grout <br /> ❑ Public ❑ Other ❑ .Delta =.i <br /> �4pprox. Depth LDEastern Surface Seal Installed by <br /> El Irrigation r State Work Done_ "x <br /> Repair Work Done ❑ Type of Pump <br /> + H.P. A <br /> Well Destruction ElWell Diameter <br /> Sealing Material (top 50') [ n�► <br /> Depth. ° Filler Material (Below 60'),_ (I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION availabllelwithin 200 feet.) I public sewer is v <br /> Installation will serve: Residence L Commercial— Other <br /> Number of living units: Number of bedrooms Rte+ <br /> Water table depth –�� <br /> Character of soil to a depth of 3 feet: r ys - No. Compartments <br /> e1Mf Capacity w 1 ' <br /> SEPTIC TANK ❑ Typ g <br /> r s �'Jr Method of Disposal <br /> PKG. TREATMENT PLT. ❑ p ` i <br /> Distance to nearest: Well <br /> Foundation Property Lir ; <br /> Total length!size <br /> LEACHING LINE ❑ No. & Length of lines property Line <br /> ❑ Distance to nearest Well Foundation <br /> FILTER BED ' <br /> ❑ Depth Size Number <br /> SEEPAGE PITS Property Line <br /> SUMPS. L]– Distance to nearest: Well Foundation P rty. <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 <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 /> such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> employ any person in ss the performan <br /> j ce of the work for which this permit is issued,I shall employ persons subject to workman"s compensa- <br /> certifies the fallowing: certify that <br /> r tion laws of California." <br /> The applicant ust call for all squired inspections. Complete drawing on reverse side. <br /> I Title: Date: <br /> Signed <br /> R DEPARTMENT USE ONLY <br /> Date Area <br /> t Application Accepted by Date <br /> Date Final Inspection by <br /> Pit or Grout Inspection by <br /> Additional Comments: Ll Tracy 83`5-6385 <br /> [I Stk 466-6781 ❑ Lodi 369-3621 _. El Manteca B23-7104 <br /> Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> Applicant <br /> CK RECEIVED BY DATE' E <br /> NO. <br /> FEE AMOUNT DUE- AMOUNT REMITTED CASH <br /> INFO 5EH 13-24(REV. <br /> EH 1428 <br />