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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 1209) 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 /> Job Address City Lot Size PM <br /> Owner's Name _.C 1 !� a�r� A e - Address J w r ! Phone <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ 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 ❑ REPAIR/ADDITION KDESTRUCTION ❑ (No septic system permitted if public sewer is <br /> '4' available within 200 feet.) 0 <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: Number of bed}�°°ms C <br /> Character of soil to a depth of 3 feet: Cif , /Ul�'t� Water table depth G <br /> SEPTIC TANK ❑ Type/Mfg Capad No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line /w <br /> F <br /> LEACHING LINE ❑ No. & Length of lines V70 Dotal length/sizerF 0 <br /> FILTER BED V. Distance to nearest: Well v7004 Foundation Property Line _ <br /> P_ <br /> 0 <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS y ❑ 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 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 California." <br /> The icant t oa for uire inspections. Complete drawing'on reverse side. ; <br /> Signed Title i [7`'[/ Dale: -7/11 <br /> FOR DEPARTMENT USE ONLY --7 <br /> Application Accepted by s` _.Date ' - Area r <br /> Pit or Grout Inspection by Date •- Final Inspection by bate <br /> -7 4 <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 i ❑ 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 /> ` INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT`NO. <br /> + EH 13 24(REV.10!831 J �S k m o ��� ��1 <br /> EH 14-26 <br />