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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 /> /_�O_b Address /'/��'o City 4 Lot Size PM <br /> Owner's Name / Address _f4�� C_o Phone <br /> Contractor ✓� Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRU <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE W OTHER WELL PITS/SUMPS \ <br /> INTENDED USE TYPE OF WELL PROBLEM AR CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Ma a Dia. of Well Excavation Dia. of Well Casing <br /> El Domestic/Private In <br /> Gravel Pack Tracy Type of Casing Specifications <br /> 1-1 Public Other Cl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _. pprox. 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 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION (No septic system permitted if public sewer is � <br /> available within 200 feet.) `a <br /> Installation will serve: Residence_ Commercial_ Other <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 No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <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 Diltrict. <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,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call foj all required inspections. Complete drawing on reverse side. <br /> Signed X�,L/,��//Gf jig/ //~� Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date ~t4 `Area/_ <br /> Pit or Grout Inspection by Date Final Inspection by �� -�^�Date AL41 <br /> Additional Comments: 77 , 6406 <br /> ❑ Stk 466-6781 O 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 <br /> INFO AMOOU/N'T" <br /> EH 14-26 ✓ rccJJJ DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT�NO. <br /> EH 3.24(REV.tiNs) ^Y� J S <br />