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1 <br /> - 1 <br /> APPLICATION FOR PERMIT <br /> e <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON-AVE; STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - <br /> (Complete in Triplicate) <br /> to the San Joaquin Local Health District for a permit to construct and/or install the work herein scribed. This application is <br /> Application is hereby made q <br /> made in compliance with San Joaquin County Ordinance Na. 549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. f <br /> Joh Address A7 's)1��� City Lot Size PM <br /> Owner's Name Address _ LS L _ Phone <br /> j <br /> Contractor Sey Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION C) SYSTEM REPAIR 171 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. <br /> FOUNDATION AGRICULTURE WELL WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM ARE STRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ ca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pac ❑ Tracy Type of Casing Specifications <br /> I Public [1 F1 Delta Depth of Grout Seal Type of Grout <br /> __­ <br /> _1 <br /> i Irrigation _..Approx. Depth l I Eastern Surface Seal Installed by - <br /> Repair Wor e ❑ Type of Pump H.P. State Work Done <br /> Well estruction ❑ Well Diameter Sealing Material {top 50'1 <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [a-REPAIR IADDITION i l.-DESTRUCTIONIN INo septic system permitted if public sewer is <br /> available within 200 feet.l <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 /> Capacity No. Compartments <br /> SEPTIC TANK EI Type/Mfg � <br /> PKG. TREATMENT PLT. ❑ Method of Disposal I <br /> Distance to nearest: Well Foundation Property Line <br /> k LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I'] Depth Size Number <br /> k SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS L7 <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 laws of California." <br /> The applicant mu ca for all requiredMpec' ns. Complete drawing on reverse side. rte, <br /> X <br /> Title: Date: <br /> Signed / <br /> OR RTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout inspection by Date Final Inspection by Date <br /> s 74 <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Appilcant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> l FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> � EH13-241REV.1/85Y <br /> EK 14-tit <br />