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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL 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.549 for sewage or No. 1882 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> t~ /� <br /> f' Job Address City 1, Lot Size <br /> PM <br /> Owner's Name Address <br /> Phone <br /> Contractr r 7 r. / <br /> Address License No 2 Z�Pha e '6O�lol <br /> TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT LlDESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANGE TO NEAREST: SEPTIC TANK .SEWER LINES <br /> 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 <br /> Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ i <br /> Specifications <br /> I'1 Public <br /> f-I Other Ll Delta Depth of Grout Seal <br /> Irrigation Type of Grout <br /> i I Irri <br /> g _--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 501) <br /> Depth Filler Material {Below 50') I <br /> a TYPE OF SEPTIC WORK: NEW INSTALLATION Rf'PAIR/ADDITION l 1 DESTRUCTION I t 1No septic system permitted if puhl7sewersxavailable within 200 feet.) <br /> Installation will serve: Residence Commercial! Other <br /> Number of living units: <br /> Number of rooms <br /> Character of soil to a depth of 3 feet: 0 y <br /> Water table depth <br /> SEPTIC TANK Type/Mfg Capacity <br /> PKG. TREATMENT PLT. ❑ r, p y No. Compartments I, <br /> Method of Disposal <br /> Distance to nearest::- Well_�15�1 Foundation [ Property Line <br /> LEACHING LINE NO'& Length of lines f Total length/size ro <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line:. <br /> ,�',(' <br /> SEEPAGE PITS Dee w <br /> pl� _ `�-�-Si�e I�lumber <br /> SUMPS Ll Distance to{nearest Y Well` Foundation .,__ <br /> --�� —_Property Line <br /> DISPOSAL PONDS ❑ r .:. <br /> I hereby certify that I have prepared 1hisfap0lication and that the work will be done-in accor8ance.with.San Joaquin county ordinances, state laws, and9� <br /> rules and regulations of the San Joaquin Cocal Health D3trict. <br /> Home owner or licensed agent's signatire certifies the following:"! 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 followincA 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." N <br /> The applicant mt t call for requi ed inspections. Complete drawing on reverse sid <br /> Signed X tt r <br /> Title: Date: <br /> FOR�DEPARTl1AENT USE ONLY <br /> Application Accepted by <br /> Date Area l <br /> �..Pit.or Grout Inspection by <br /> Date ` Final Inspection by — Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 <br /> Applicant - Return afl-copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK 41 <br /> INFO <br /> CASH.- RECEIVED BY DATE PERMIT'NO. <br /> +.EH 13-241REV.1/851 <br /> EH 14-26 <br /> f�Lt <br /> k <br />