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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CAokXCAL <br /> � � � <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> :. <br /> A Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and t <br /> and/or install the work herein described. This application is r <br /> he Rules and Regulations of the San Joaquin + <br /> Local'Health District. <br /> LM " Lot Size PM <br /> Js – -.— � `Y��l T°�✓ — city <br /> Job Address t <br /> Name <br /> �Q/tf 1a�,v Address <br /> wner's . O__�. �� YR ��Efj�ILL <br /> License No. Phone_ <br /> Contractor� Address , <br /> TYPE OF WELLIPUMP: _ NEW WELL ❑ WELL REPLACEMENT IJ DESTRUCTION El <br /> PUMP INSTALLATION CJ - SYSTEM REPAIR ❑ OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE. <br /> DISTANCE TO NEAREST: SEPTIC TANK \ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Specifications - <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy � Type of Casing t Type of Grout <br /> [-I Public ❑ Other ❑ Delta Depth of Grout Seal - <br /> I I Irrigation Approx. Depth I 1 Eastern Surface Sea! Installed by <br /> Repair Work Done ❑ Type of Pump <br /> H.P. State Work Done _ <br /> Sealing Material (top 50') <br /> Well Destruction ❑ Well Diameter 9 <br /> Depth <br /> } Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION E I DESTRUCTION I alvo septic <br /> ailable hitem permitted if public sewer is ? <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Number of bedrooms <br /> Wa[er table depth <br /> Character of soil to a depth of 3 feet: <br /> Capacity No. Compartments <br /> SEPTIC TANK C1 Type/Mfg <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> :- - <br /> Distance to nearest: Well Foundation Property Line I <br /> LEACHINGLINE ❑ No. & Length of lines Total length/sizer <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS V I Depth Size — Number <br /> Property Line <br /> t: Well Foundation P Y <br /> SUMPS L� Distance to nearest: . <br /> DISPOSAL PONDS ❑ <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 applican must calf for all required inspecti S. Complete drawing on reverse side. Q <br /> Signed X Title: Date: t+ <br /> FOR WARTMENT USE ONLY <br /> Application Accepted by 0Z 1". <br /> Date tea <br /> I Date Final Inspection by Date ` 7. <br /> Pit or Grout inspection by <br /> Additional Comments- 13 a U `� <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Menteca 823-7144 ❑ 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 /> FEEAMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT NO. <br /> rEH13-24iREV.1/Ksl 5s ,Ofl <br /> EH 14-26 .fly <br />