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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 /> permitth District for a herein application <br /> Application hence with a to theSan Joaquin qu n County Local Heal No.549 for sewage or No. 1862 for welP pump and the Rules and Regulations of the SanJoaquin <br /> l <br /> made P <br /> Local Health Dist ict. <br /> City. Lot Size PM <br /> Job Address <br /> Phone Cf 0 <br /> Owner's Name <br /> Address <br /> e No. Phone <br /> Contractor <br /> NEW WELL WELL REPLACE NT ❑ DES PUCTION ❑ <br /> TYPE OF WEL / U P:' SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION F) �C <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> WELL OF <br /> TYPE <br /> PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE Dia. of Well Casing <br /> El Industrial ❑ Open Bottom L1 Manteca Dia. of Well Excavation <br /> Type of Casing Specifications <br /> L7 Domestic/Private 171 Gravel Pack [I Tracy <br /> Type of Grout <br /> ('l Public ❑ Other 0 Delta Depth of Grout Seal <br /> I I Irrigation —_.Approx. Depth I 1 Eastern Surface Seal Installed by <br /> H.P. <br /> to Work Dane _ <br /> Repair Work Done ❑ Type of Pump x_ <br /> I <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material (Belo 11 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION DESTRUCTION availSept within 200 permitted if public sewer is <br /> Installation will serve: Residence— Commercial _ Other' <br /> Number of living units: Number of bedrooms t Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> PKG. TREATMENT PLT. ❑ ' Y <br /> ( Method of Disposal <br /> Distance to nearest: Well Foundation's Property Line— <br /> I �' ' Total length/size—^� "'"" s <br /> LEACHING LINE ❑ No. & Length of lines <br /> a FILTER BED El Distance to nearest: A Well. Foundation Property Line <br /> i <br /> SEEPAGE PITS C I Depth Siie Number _ <br /> SUMPS <br /> ❑ Distance to nearest: Well Foundation Property Line f. r <br /> ' <br /> I <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 /> k 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�l shall not <br /> 1 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 pe ormance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call all uired ins cti ns. Comple a ing on re $i e. <br /> � Signed X <br /> Title: Date: <br /> FOR D,EPA NT USE ONLY <br /> ���r— I <br /> Date Area <br /> I Application Accepted by I -Y z v` <br /> Date Final Inspection by Date-7, <br /> Pit or Grout Inspection by <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-362 Wntac, 823-7104 1 ❑ Tracy 5-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE CK RECEIVED BY DATE PERMIT NO. <br /> EAMOUNT DUE AMOUNT REMITTED CASH <br /> F INFO 3F7/7/3 <br /> 1j�p <br /> Com" 7-r1- C10 f 7> <br /> r EH 13-241REV.tlH51 <br /> EH 14-28 <br />