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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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address ��' [ l �r+�,G�n City rJ Lot Size PM <br /> Owner's Name Address �Ef -&-e �VPhone " <br /> Contractor's Nam . ? tc9( <br /> License No. ,X3; <br /> — � r Phone <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 v, <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by N <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.) ,r+� <br /> Installation will serve: Residence t_­1Commercial_ Other <br /> Number of living units: -I Number of bedrooms — t <br /> Character of soil to a depth of 3 feet: <br /> Water table depth - <br /> SEPTIC TANK I i Type/Mfg Capacity_fj2!�! No. Compartments <br /> PKG. TREATMENT PLT. ❑ 0 <br /> 11Method of Disposal <br /> Distance to nearest: Well Foundation Property Line 57 <br /> LEACHING LINE 93' No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: I Well Foundation <br /> �_ Property Line <br /> SEEPAGE PITS CT--Depth Size _ �n Number ` <br /> SUMPS ❑ Distance to nearest: Well C f <br /> Foundation /D Property Line 31 <br /> DISPOSAL PONDS ❑ <br /> 1 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 ust call for I re uired inspections. Complete drawing on reverse side <br /> 1 <br /> Signed Title: ' Date: -,?T <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date �"�p Area <br /> "r Grout Inspection by Date !� � Final Inspection by� l Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ 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 AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT"N0. <br /> + EH 10 26(REV.10/831 c� �S% 'ROa� <br />