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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �T D <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 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. Aqu' �• <br /> �" i 7 3 <br /> Lot Size PM <br /> Job Address City 11� // <br /> Owner's Name @'�1 a ddress-3 1 [1 <br /> Contractor <br /> Address License No J -13 72_._Phone <br /> TYPE OF WELL/PUMP: NEW WELL 177 WELL REPLACEMENT L1 DESTRUCTION Ll <br /> PUMP INSTALLATION C' SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca 4 Dia. of Well Excavation <br /> Type of Casing Specifications <br /> Q'Domestic/Private LJ Gravel Pack ❑ Tracy Type of Grout <br /> 1:1 Public E3 Other <br /> ❑ Delta Depth of Grout Seal <br /> ❑ Irrigation ---Approx. Dept ❑ Eastern Surface Seal Installed by 4� <br /> IH.P------ State Work one <br /> Repair Work Done ❑ Type of Pump <br /> Well Destruction ❑ Well Diameter, Sealing Material (top 501 <br /> Depth Filler Material {Below 501 f ! <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION 11anvailablleseptic <br /> witsystem <br /> ne200 permitted <br /> tted if public sewer is <br /> eettl� <br /> ,:fristallation will serve: Residence Commercial Other <br /> 1 --Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: <br /> Ca <br /> SEPTIC TANK 17 Type/Mfg <br /> pacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property,tine <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> Size Number ,i <br /> SEEPAGE PITS El Depth <br /> i <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line T_.. <br /> + DISPOSAL PONDS ❑ <br /> he work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and that t <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 /> t 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." II f i <br /> The applicant t all for allrequiredinspections. Complete drawing on reverse side. <br /> Signed <br /> .f ' itle: � `Date: <br /> -" DEPARTMENT USE ONLY <br /> — Date—�d Area <br /> f !application Accepted by i(Z �� <br /> Pit or Grout Inspection by <br /> Date Final Inspection b� Date <br /> - Additional Comments: <br /> ❑ Stk 466-6781 [1 Lodi 369-3621 17Manteca 823.7104 ❑ Tracy 835-6385 <br /> 1 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 /> INFO ss Af1MOUNT DUE AMOUNT REMITTED CASH <br /> 4[ + EH 13-24{REv.t/est <br /> { EH 14-29 ! t' <br />