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APPLICATION;EOR. PERMIT <br />SAN JOAQUIN :LOCAL.HEALTH DISTRICT <br />11984 1601 E. HAZELTON AVE., STOCKTON, CA <br />Telephone (209) 466-6781 <br />OM DATE ISSUED <br />SAN JOAQUI N LOCAL PERMIT EXPIRES 1 YEAR FR <br />IHFA1.TH DISTRICT (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 <br />ir <br />City Lot Size <br />r <br />Owner's Name Address <br />Phone <br />Contractor's Name License No. <br />�L�Phone <br />TYPE OF WELL/PUMP: NEW WELL ❑ <br />PUMP INSTALLATION ❑ <br />DISTANCE TO NEAREST: SEPTIC TANK <br />FOUNDATION <br />INTENDED USE <br />❑ Industrial <br />Q'Dornestic/ Private <br />❑ Public <br />❑ Irrigation <br />Repair Work Done ❑ <br />Well Destruction ❑ <br />WELL REPLACEMENT ❑ DESTRUCTION ❑ <br />SYSTEM REPAIR,r,e' OTHER Gi-` <br />SEWER LINES DISPOSAL FLD. PROP. LINE _ <br />AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />TYPE OF WELL <br />PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />❑ Open Bottom <br />❑ Manteca Dia. of Well Excavation <br />❑ Gravel Pack <br />❑ Tracy Type of Casing <br />❑ Other <br />❑ Delta Depth of Grout Seal <br />---Approx. Depth <br />❑ Eastern Surface Seal Installed by <br />Type of Pump ASiJdi H. P. State Work Done _ <br />Well Diameter <br />Sealing Material (top 501 <br />Depth <br />Filler Material (Below 501 <br />Dia. of Well Casing <br />Specifications <br />Type of Grout_ <br />TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permittee <br />available within 200 feet.) <br />Installation will serve: Residence _ Commercial _ Other J1 <br />Number of living units: Number of bedrooms , <br />Character of soil to a depth of 3 feet: Water table depth <br />SEPTIC TANK ❑ Type/Mfg Capacity" 1' ,No. Compartments _ <br />PKG. TREATMENT PLT. ❑ ti y �f� Method of Disposal _ <br />Distance to nearest: Well ! °Foundation Property Line <br />AI <br />LEACHING LINE ❑ No. & Length of lines <br />FILTER BED ❑ Distance to nearest: <br />Well <br />Foundation <br />Total <br />Property Line = <br />c.� <br />SEEPAGE PITS ❑ Depth Size Number ' <br />SUMPS ❑ Distance to nearest: Well Foundation Property Line <br />DISPOSAL PONDS ❑ <br />public sewer is <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 m st Vill f r a)required inspections. Complete drawing on r rse side. <br />Signed+��� Title: —� Date: <br />FOR DEPARTMENT USE ONLY <br />Application Accepted by � Date ` Area *' <br />Pit or Grout Inspection by Date Final Inspection by I -or- (4 Av.,.,a... Date 10" <br />Additional Comments: — <br />❑ Stk 466-6761 ❑ 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 />+ EH 1324 (REV. 10/83 <br />EH 14-28 <br />FEE <br />AMOUNT DUE <br />AMOUNT REMITTEDMH <br />RECEIVED BY DATE <br />PERMIT"NO.INFO <br />It"i <br />S . <br />J <br />e_�:* - % CT ll� <br />gkf <br />s <br />N <br />Ci <br />C <br />