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r` <br /> GO <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT AUG I <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 SAN J(OAQi,..11`IZi LOCAL <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED HEALTH DISTRICT <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 Addressf <br /> - City Lot Size PM <br /> Owner's Name4QL Address <br /> ��,pr Phone 2 <br /> Contractor's Name '�G� License No. !2 JR,' QJV, Phone Y,� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP'INSTAL-LATION ❑ SYSTEM REPAIR ❑ ---OTHER-�nti+_� - »- <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 /> /27 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 1 <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work,Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') Y I <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION'❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.► ! <br /> Installation will serve: Residence_ Commercial_° Other (� I <br /> Number of living units: 1 Number of bedrooms - J <br /> Character of soil to a depth of 3 feet: j Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal 1 ; <br /> Distance to nearest: Well Foundation Property Line <br /> I� <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line fn1 <br /> -!SEEPAGE PITS, ❑ Depth Size Number <br /> SUMPS <br /> ❑ 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. I <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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must tali for all required inspections. Complete drawing on rev side. (] ] <br /> Signed 932 - Title: Date: <br /> FOR DEPART ENT USE ONLY <br /> i <br /> Application Accepted by Date U - �� Area / r! <br /> Pit or Grout Inspection by ,�-- Date �Final Inspection by Date" <br /> Additional Comments: <br /> ❑ 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 2009, Stk., CA 95201 t <br /> FEE AMOUNT DUE <br /> INFO AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"N0, <br /> + EH 1324(REV.14/831 [� <br /> EH 1428 [90 ^-a <_-.,E� ��Z3 <br />