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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE 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 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.548 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. r <br /> Job Address City PM <br /> Lot Size <br /> r Phone <br /> ZJ <br /> Owner's Name Address <br /> Z . <br /> ZZ fi- <br /> Contractor <br /> Address I —WLicense No/ Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ - <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 /> C1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 11 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout — <br /> I I Irrigation _Approx. Depth i I Eastern Surface Seal Installed by <br /> Repair Work Done ElType of Pump N.P. State Work Done <br /> Well Destruction ❑ Weil Diameter Sealing Material (top 50' <br /> y <br /> Depth Filler Material (Bel 50'1 { <br /> _ i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I.) REPAIR/ADDITION DESTRUCTION I i aNailabpticsy temin feeti <br /> JNo ted if public sewer is <br /> Installation will serve: Residence_ Commercial— Other <br /> E <br /> Number of living units: Number of bedrooms [Ci• <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑,, Type/Mfg ; ' Capacity No. Compartments �`\T <br /> PKG. TREATMENT PLT. 171 <br /> of Di osal <br /> Distance to nearest: :Well / Foundation�._..—.Property Line <br />. a <br /> LEACHING LINE ❑ No. & Length of lines' r� �Total length/size <br /> FILTER BED EIDistance to nearest: Well f oundation S �J„�...— Property Line - <br /> 48 <br /> ' , <br /> SEEPAGF PITS I i Depth's"i���yt Number <br /> Well _ Foundation f f Property Line <br /> 11 Distan <br /> ce,to nearest. <br /> SAL PONDS ❑ - 1 <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: "1 certify that in the performance of the work for which this permit is issued, 1 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.parsons subject to workman's compensa- <br /> tion laws of California." , <br /> The applicant must c or Ire r d nspect ns. ate drawing on reverse side. <br /> � Signed X <br /> Title: Date: <br /> O EP�� ARTMENT USE ONLY � t�., <br /> Application Accepted by Q�� Date �' U Area <br /> � O Date�7_�Ld <br /> Pit or Grout Inspection by Date 7 Final Inspection by' <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health-Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> ffZ0NT DUE AMOUNT REMITTEO CASH CK S RECEIVED BY DATE PERMIT-NO. <br /> `/+�'[�J <br /> EH 13-24(REV.t i H 5] � + T <br /> EH 14-28 <br />