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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT y <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> - r <br /> (Complete in Triplicate) <br /> fApplication 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 /> f made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> -Local Health District. <br /> c: + City N �Cye Lot Size PM <br /> Job Address <br /> -u. qqi* :.. <br /> Owner's Name U Address - Phone <br /> 5 ContractorAddress 64 ! E icense No Phone <br /> F WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 1:1 <br /> k P INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TA SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION TUBE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CON TION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Exca Dia. of Well Casing <br /> ❑ Domestic/Private El Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 11 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> i Repair Work Done ❑ Type of Pump H;•P.` t State Work Done <br /> Well Destruction ❑ Well Diameter Sealing,Material Itop 501 <br /> r Depth Fil ler'Material IBelow 501 f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ iDESTRUCTIOM (No septic system permitted if public sewer is Tf <br /> available within 200 feet.) I I <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> r Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal <br /> I Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size " " Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Cl <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 /> 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 equire "ins tions. Complete drawing on reverse side. <br /> ( <br /> Signed X Title: Date: <br /> FOR DEPART ENT USE ONLY �j <br /> Application Accepted by Date "' Area <br /> Pit or Grout Inspection by Date Final Inspection by Date ✓ S <br /> t <br /> Additional Comments: <br /> ❑ Stk 466-67810 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED H RECEIVED BY DATE PERMIT"NO." <br /> INFO / <br /> +EH 13-24(REV.1'/B 5) S <br /> ( EH 14-25 <br />