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APPLICATION FOR PERMIT , <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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 fora permit to construct and/or install the work herein described.This application is <br /> made a on is ancby maith San Joaquin County Ordinance Na.549 for sewage or No. 1862 for well/PUMP and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> s <br /> Ci Lot Size PM <br /> Job Address. <br /> ® � Phone <br /> Owner's Name <br /> Address <br /> Phone) <br /> Contractor's Name' <br /> License Nq< <br /> TYPE OF WEL4IPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DRSTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SY •flEPAIR STEMEl OTHER 11 <br /> ­.�' % DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBL_ E AREA' CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation i Specifications <br /> h i f Casing <br /> p <br /> ?-Domestic/Private ❑ Gravel Pack ❑ Tracy Type o 9 # Type of Grout S- <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal M ,I <br /> ❑ Irrigation --Approx. De �h /❑ Eatstern urface Seal Installed by <br /> ,4,4r t H P State Work Don <br /> i Repair Work Done l� Type of Pump I <br /> ( Well DestructionY LiWell Diameter Sealink Mateglal (top`50") 4, <br /> € Depth Filler Material (Below-54'} j <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑- REPAIR/ADDITION ❑—DESTRUCT1ON�d'`aNailabltic system <br /> m feet/ is <br /> ted if public sewer Z <br /> Installation will serve: Residence— Commercial Other <br /> Number of living.units% - L Nurblti,::of bedroom s,�-�--�-- -----� <br /> r. <br /> ✓ ", Water table depth <br /> Character of soil to a depth of 3 feet: ,1 "• No. Compartments <br /> Capacity <br /> I SEPTIC TANK ❑ Type i ti Method of Disposal <br /> PKG. TREATMENT PLT. ❑ , Property Line <br /> 1 Distance to nearest: well Foundation <br /> f }` Total length/size <br /> LEACHING LINE ❑ No. & Length of lines a `"` oroperty Line <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> Number <br /> SEEPAGE PITS C1Depth Size <br /> It Property Line <br /> SUMPS ❑ Distance to nearest: wall-,— .Foundation <br /> DISPOSAL PONDS ❑ ' <br /> I I hereby certify that I have prepared this application andlthat the work will be done in accordance withe <br /> 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 Work for which this permit is issued, I shall not <br /> I employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub contracting signature <br /> certifies the following:"I certify that in the performance i the work for which this permit is issued,I sh11 employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant 49,ca I for uired inspections. Complete drawin on teverse side.S° <br /> r Date: <br /> )`,,Title: <br /> Signed <br /> FOR DEPARTMENT USE ONLY } <br /> Date Area <br /> Application Accepted by (� <br /> Final Inspection by Date <br /> Pit or Grout inspection by Date <br /> Additional Comments: <br /> ❑ Stk 46&6781 ❑ Lodi 369-3521 C7 Manteca 823-7104 [I Tracy 8:i5-6385 <br /> alth Permit/ices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> Applicant- Return all copies to: Environmental He <br /> FEE <br /> CK* RECEIVED BY DATE PERMWNO. <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> + EH 13-24 IREV.101831 - <br /> EM 14-28 — -- <br />