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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED + <br /> St�u�Ord4_��4V (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. � 1112 <br /> Job Address - -s <br /> City <br /> Lot Size PM <br /> 4Owner's Name Address / / Phone <br /> Contractor " ' 4 '4& Address 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 FLO. 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_ �(D Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f'i Public (_! Other ,-- - <br /> k ❑ Delta Depth of Grout Seal Type of Grout <br /> t - <br /> I I Irrigation Earstern­—.- Surface'Seai lnstarfed hy-------w.-_,_� <br /> Repair Work Done ❑ *Type of Pump H.P. State Work Done <br /> Well Destruction © Well Diameter . XSealing Material (top 501 <br /> - Depth .r�� �'f .f , ✓� Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTA TION LI REPAIR/ADDITIOIV.I I DESTRUCTION (No septic system permitted if public sewer is <br /> f, � E °"- ;I i. available within 200 feet.) e� <br /> Installation will seine: Residence_' Commercial Other t <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK'- 1❑ Type/Mfg '`Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> aA <br /> LEACHING LINE ❑ No. & Length of lines <br /> I Total length/size <br /> , <br /> FILTER BED $ ,4 ❑' Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS F 11 Depth Size Number <br /> SUMPS, <br /> ,r '•_ Ll Distance to nearest: 'Well Foundation Property Line 1 <br /> DISPOSAL PONDS t C1 <br /> I hereby certify that t have prepared this app)r d 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 H th District. <br /> Home owner or licensed agent's signature certifies t e following: "I certify that in the performance of the work for which this permit is issued, 1 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 /> F' The applicant mu for II eyuired inspections. Complete drawing on reverse side. <br /> Signed - Title: — = <br /> Date: <br /> y DEPARTMENT USE ONLY <br /> Application Accepted by v\ _ Date <br /> Area <br /> Pit or Grout Inspection by y\\ ate �' '� Final Inspection by pate <br /> Additional Comments: ? <br /> ❑ Stk 466-6781 ❑ odi 369 3621 ❑ Manteca 823-7104 XTracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,--Stk., CA 95201 <br /> ' r INFO-4 <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> RECEIVED BY DATE PERWT'NO. <br /> + EH13-24 I REV. <br /> EH 14.28 <br />