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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 /> r 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. 544 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> LJobdress d City of Size PM <br /> s Name (/�r8 Address _U i Phone S��actor Address 'License No. Phone <br /> TYPE OF WELL/PU NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑` SYSTEM REPAIR ❑V, _ OTHER ❑ <br /> - <br /> DISTANC€ TO NEAREST: SEPTIC TANK SEWE INES ` AL,FLD. PROP. LINE <br /> FOUNDATION--___- AGRICUL RE WELL' OTHER-WELL- - PITS/SUMPS- <br /> a INTENDED USE TYPE OF WELL PROBLEM AREA C T TION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Di . of ell Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> FI Public F1 Other tl [�l D� e//lta Depth of Grou eel Type of Grout _ — <br /> I I Irrigation Approx. Depth�--t-I-Eastern- Surface Seal Instaile by <br /> Repair Work Done ❑ Type of.Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION [ I DESTRUCTION" (No septic system permitted if public sewer is I^ <br /> vailable within 200 feet.) <br />' Installation will serve: Residence_ Commercial'— Other <br />€ Number of living units: Number of bedrooms M <br /> Character of soil to a depth of 3 feet: Water table depth k I J <br /> SEPTIC TANK ❑ Type/Mfg_ Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ r Method 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 /> SEEPAGE PITS i I Depth Size — Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <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 /> t 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 c II for requi Ed i s ctions. Complete drawing ori reverse side. ry <br /> \Signed X Title: l f`�"``f Date: <br /> r� <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date �. /.. Area - <br /> s Pit or Grout Inspection by — <br /> ­Date Final I tion by Date <br /> Additional Comments: ; �` V I <br /> ❑ Stk 466-6781 El Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 O <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 <br /> i <br /> FEE AMOUNT DUE AMOUNT REMITTED CK- RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> I ����, �� l <br /> t EH 13-24 IREV,1/95) <br /> EH 14.28- - <br /> r <br />