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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. KAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES T YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> de to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. he San Joaquin <br /> application is <br /> Application is hereby ma <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for weli1pump and the Rules and Regulations of th <br /> Local Health District. I r <br /> 1 <br /> City Size PM <br /> I <br /> Job Address 7 <br /> + ` Phone <br /> dress <br /> Owner's Name 6 <br /> lr ansa No. Phone � <br /> dress <br /> Contractor WELL REPLACEMENT DESTRUCTION ❑ <br /> TYPE OF WE L ! P: NEW WELL ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ SYSTEM:REPAIR ❑ <br /> SEWER LINES DISPOSAL FLD. POOP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITSISUMPS <br /> �— <br /> AGRICULTURE WELL OTHER WELL <br /> FOUNDATION <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE - Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca -Dia--of well Excavation Specifications <br /> I` ❑Tracy Type of Casing <br /> I , .• , EJ DemesticlPrivate ❑ Gravel Pak Type of Grout <br /> r. I�'Other ❑ Delta Depth of Grout Seal <br /> Fl 1 Public «} Surface Seal Installed by <br /> I 1 Irrigation _Appro;. Depth l I Eastern H.P. State Work Done <br /> Type of Pump �--- <br /> Repair Work Done ❑ s } Sealing Material (top 50') U <br /> Well Destruction ❑ <br /> Well Diameter <br /> Depth i Filler Material ..Belo 50') <br /> t T �.,��� S I R _ „I ( available-within 200 feet.) �] <br /> :..� TYPE QF SEPTIC WORK: NEW INSTALLATION Ll REPAIfllADDITION DESTRUCTION l 1 (No septic system permitted if public sewer is <br /> Commercial Other��� <br /> Installation will serve: Residence � - <br /> Number of living units: _L_ Number-of bedr s Water table depth <br /> Character of soil to a,depth of 3 feet: Capacity�� No. Compartments <br /> F SEPTIC TANK O Type/Mfg t Method of Disposal <br /> I TREATMENT PLT. ❑ • <br /> Foundation Property Line <br /> { Distance to nearest: Well :- <br /> n ze <br /> LEACHING LINE O No. & Length of lines pro er[ Line <br /> Foundation p y <br /> FILTER BED ❑ Distance to nearest: Well . f` <br /> Size Number <br /> SEEPAGE PITS 11 Depth Foundation Property Line <br /> SUMPS f l Distance to nearest: <br /> f� Well <br /> k ti,. <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 /> d, I shait not <br /> rules and regulations of the San Joaquin Local Health District. work for <br /> ermit is issue <br /> Home owner or licensed <br /> ch manner as torbecome subOctt to workman's kman's�compensation lity that in the aws <br /> soof Califon aha Contractor slhir ngr oPsub contract ng signature <br /> employ any person in such <br /> f certifies the following: u certify that s the performance of the work fgr_wfiich.this"perritit i ped, I shall employ persons subje6 t to workman's compensa <br /> tion laws of California." I <br /> The applicant m st call r a quire s ctions.'Compla drawing on reverse side. <br /> pate: <br /> Title: <br /> I Signed X � 1 <br /> R DEPARTMENT USE ONLY 4^ <br /> pate Area , <br /> Application Accepted by 'x <br /> Final Inspection by ate <br /> ' �. .,--... , <br /> Pit or Grout Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623 7104 ❑ Tracy 835- <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009. Stk., CA 95201 <br /> CK RECEIVED BY DATE PERMIT NO. <br /> LL FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> � + EH 13-24{REV.1 k 51 <br /> i, EFI14-28 .. <br />