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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON 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. /j3 ��f <br /> ( 01 0 � <br /> Job Address '] Cit Lot Size PM <br /> Owner's Name s Address Phone <br /> Contract C Address License N L1l �� Phone ` <br /> TYPE OF WELLlPUMP: 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 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> F] Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F) Public F1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> i I Irrigation _L__Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Hone ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Wel! Diameter Sealing Material {top 50'1 <br /> Depth- Filler Material Melow 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION E I DESTRUCTION 1 1 INo septic system permitted if public sewer i <br /> available within 200 t.1 <br /> Installation vA serve: Residence_ Commercial Other /f�C, <br /> Number of living units: . Number of bedr ms f <br /> Character of'soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK �TypelMfg Capacity No. Compartments <br /> p <br /> PKG. TREATMENT PL ❑ f f Method of Disposal r <br /> Distance to nearest: Well.__ Foundation" �Q Property Line <br /> LEACHING LINE & Length of lines �q Total length/size f <br /> FILTER BED } ❑ Distance to nearest: Well _. Foundation_f� Property Line <br /> A f/ <br /> SEEPAGE PITS . Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation A&I .— Property Line <br /> DISPOSAL PONDS " _ ❑ <br /> hereby certify thaf 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 DAtrict. <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." Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in,the peformance 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 mu for all it inspections. Complete drawing on never <br /> Signed X <br /> '~• Title: <br /> s FOR D ARTMENT USE ONLY <br /> ' <br /> Application Accepted by — Date Area <br /> it r Grout Inspection by ate - incl Inspection by Date <br /> Additional Comments: bJ'5 _'- I <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835-638 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazolton Ave., .O. Box 2009, Sik., CA 95201 <br /> .FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO t <br /> r.EH 13-24(REV,I <br /> EH 14-28 <br />