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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 he+eby 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. rX <br /> Job Address City Lot Size PM <br /> Owner's Name Address PO I-S' 4 1:4� Phone 33 03� <br /> ` <br /> Contract� Address C r License No Phone3{09-5 S— <br /> DESTRUCTION 1-1TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El <br /> s <br /> ` <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 C] Other E1 Delta Depth of Grout Seal Type of Grout <br /> I 1 Irrigation ­Approx. Depth I I 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') ` <br /> _ Depth Filler Material (Below 501 _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION W�REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence 0--l' Commercial Other <br /> Number of living units: A— Number bedrooms C <br /> Character of soil-to a depth of 3 feet: / Water table depth J <br /> r :�Type/Mfg Capacity 1(000 No. Compartments <br /> SEPTIC TANK <br /> PKG. TREATMENT PLT. ❑ � j Method of Dysposal " <br /> Distance to nearest: Well mss-'— Foundation �_0 Property Line — <br /> w <br /> notal length/size O x <br /> LEACHING LINE Pf No. & Lengih o ,.f-Iiries z <br /> FILTER BED ❑ Distance t.'nearest-,.—Well 0 .Foundation_._��. Property Line .r] <br /> SEEPAGE PITS W--Depth Size tNumber <br /> r- <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line�— <br />` 'DISPOSAL PONDS [Dr� <br /> I hereby certify that 1 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." �1* <br /> R The applicant must call for all required inspections.-Complete drawing ing on reverse side. <br /> Signed,-X <br /> .7itle: - Date: f <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date <br /> Pit r Grout Inspection by Date Final Inspection by Date <br /> r <br /> Additional Comments: _ - <br /> C1 Stk 466-6781 Q Lodi 369-3621 ❑ Manteca 823-7104 C] 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 /> i <br /> t <br /> FEE AMOUNT DUE 'MoREMITTED CK RECEIVED BY DATE PERMIT_NO. <br />�4 INFO CASH <br /> 1 c ? <br /> a EH 13-24(REV.1/x 5) i U <br /> i EH 14-2e <br />