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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <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 /> 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 Address ��!%z N �f/O„7T City Lot Size C�4 C PM <br /> Owner's Name C`� C��O Address �� ` L I �l`' Phone 36,9 r� <br /> Contractor's Name License No. _30- Phone 3�3 <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 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 /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <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 501 <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 PJAZI <br /> Number of living units: --t— Number of. edrooms 2- f <br /> Character of soil to a depth of 3 feet: C. _ . t d q�� Water table depth <br /> SEPTIC TANK ❑ Type/Mfg 06PJ - C Capacity___ r`23-�+ No. Compartments 2- <br /> PKG. TREATMENT PLT. ❑ ff 1 Method of Disposal <br /> Distance to nearest: Well c I Foundation 1..�_..._ Property Line f On ! <br /> LEACHING LINE Q-'-No. & Length of lines O/ Total length/size f <br /> FILTER BED ❑ Distance to nearest: Well c�_. Foundation a2=0 Property Line r <br /> SEEPAGE PITS [!�—bepth Size *' Number 2— <br /> SUMPS ❑ Distance to nearest: Well3l)_Z) 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. <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 call for all r q 're inspections. Complete drawing on reverse side. <br /> Signed Title: �/� Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area f� <br /> Pi or Grout Inspection by _ !i Date inal Inspection by ��/ Date <br /> Additional Comments: Idl <br /> ❑ Stk 466-6781 C1 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 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. <br /> + (REV.10!631 <br /> EH 14-26 d <br />