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y 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 /> all the work <br /> n described. This <br /> cation <br /> madlec incompliancewuh San Joaquin County ordinance o.549 for sewage oreafth District for a 'No. 1862 fort to cweli/dpump atnd the R les and 1Regulations of he San'Joaquin <br /> is <br /> Local Health District. <br /> ity Lot Size PM <br /> Job Address <br /> Y 'r ` --� <br /> r Address Phone <br /> -(Owner's Name <br /> Address License No. Phone <br /> tontra fID <br /> DESTRUCTION ❑ <br /> TYPE OF WE NEW WELL WELL REPLACEMENT ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES \ <br /> x 'FO614 ATION,- AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial`a ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Type of Casing Specifications <br /> ❑ Domestic/Private <br /> 13 Gravel Pack ❑ Tracy Yp g T of Grout <br /> n Public n Other Cl Delta Depth of Grout Seal Yt� - <br /> I 1 Irrigation "+G' _Approx. 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 {p <br /> e'" Depth l=itter Material {Below 50'} <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l l HEPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is (� <br /> _ available within 240 feet.) <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of sail to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 11Method 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 /> Number <br /> SEEPAGE <br /> SEEPAGE:PITS -I I Depth Size <br /> SUMPS t 0 Distance to nearest: Well Foundation Property Line <br /> r <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 /> I' rules and regulations of the San Joaquin Local Health Di§trict. <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 laws of California." <br /> The applicant must tail for all required inspections. Complete drawing on reverse side. <br /> Title: Dace: <br /> Signed <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> I Pit gr Grout Inspection by Q Date Final Inspection by <br /> Date ` <br /> Additional Comments, ° <br /> ❑ Stk 465.6781 ❑ Lodi 369-3621 1 ❑ 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 AMOUNT DUE AMOUNT REMITTED CASH RECfIVED BY_ DATE PERMITNO. <br /> INFO e4., <br /> EH 11.28 <br />