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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL ION AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> quin Health <br /> r cation is <br /> Applicationihereby <br /> maith a totheSan Joaquin CouJoe nty OrdinanceD <br /> nce No.549 for sewage or permit <br /> 1862 for well/pump install described. <br /> Local nd the Rules and R gulat oof he San'Joaquin <br /> l <br /> madecompliance <br /> Local Health District. <br /> City Lot Size Z0 PM <br /> Job Address <br /> Phone Z 7 S� <br /> " Owner's Name Address 1-+jj <br /> r ` ,r �f Phone 7 <br /> Contractor's Name License No. <br /> I4 DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT; 6' �w OTHER ❑ <br /> `-�P,UMP INSTALLATION ❑ NYSTEM�REPAIR`1] " ' <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE•TO NEAREST: SEPTIC TANK SEWER LINES <br /> AGRICULTURE WELL%, OTHER WELL PITS/SUMPS <br /> FOUNDATION —•- <br /> INTENDED USE TYPE OF WELL PRO� EM AREA CONSTRUCTION SPECIFICATIONS <br /> BLDia. of Well Casing <br /> ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing Specifications <br /> ❑ Domestic/Private El Gravel Pack C2 Tracy Type of Grout 1 <br /> ❑ Public L3 Other El Delta Depth of Grout Seal .1 <br /> 1-5 Irrigation --Approx. Depth ❑ Eastern Surface Seal installed by <br /> H P State Work Done I ( , <br /> Repair Work Done E3 Type of Pump w <br /> Well Destruction ❑ Well Diameter Sealing Material )top 501 <br /> t Depth :Filler Material (Below 50'} <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION (DESTRUCTION,❑r availablelwthine200 feet.) if publicsewer is <br /> Installation will serve: Residence)� Commercial— Other 1 <br /> r Number of living units:. Number of bedrooms . Water table depth <br /> Character of soil to a depth of 3 feet:! — a No. Compartments I <br /> SEPTIC TANK �❑ Type/Mfg Capacity <br /> Meth6I <br /> d of, Disposal <br /> PKG. TREATMENT PLT. ED <br /> Distance to nearest: Well Foundation Property oe .r <br /> ! j <br /> r .✓ <br /> r LEACHING LINE ' No.'& Length of lines Z 7-� Total length/size <br /> FILTER BED #❑ Distance to nearest: Well f Foundation jo - Property Line <br /> _ 1 <br /> SEEPAGE PITS Depth <br /> 2- 5 _Size Number" 2 ' <br /> . <br /> SUMPS Foundation��Q--�property Line — <br /> ❑ Distance to nearest: Well _4 <br /> DISPOSiAL"PONDS ❑ <br /> I hereby certify That I have prepared this application and that the work will be done in ace ordance witFi San Joaquin county,ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> "I certify that in the1:performance of the work for which this permit is Issued, shall not <br /> Home owner or licensed agent's signature certifies the following: <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 shalt employ persons subject,to work�n's compensa- <br /> tion laws of California." yy <br /> The applicant st c for all u'ed inspections. Complete drawing on reverse side <br /> Signed Title: , `�— Date: <br /> _ �, •'ti# � � • <br /> FOR DEPART ENT USE ONLY t ) <br /> Area <br /> Date <br /> Application Accepted by <br /> ' j � Dates <br /> Pit or Grout Inspection by p i Date U Z19 Final Inspection by <br /> r, <br /> Additional Comments: = 1 <br /> ❑ 5tk 466-6781 ❑ Lodi 369 3G11 ❑ Manteca 823-7104 T acy 83�"M <br /> Applicant Return all copies to: Eri 9-3621 iital Heakh'Permit/Seivices 1601 E. Hazelton A1ie.; P.O.'Boz 2009,Stk, CA'95201 <br /> FEE CK RECEIVED BY DATE PERMIT°NO. <br /> INFO AMOUNT DUE. AMOUNT REMITTED CASH <br /> + EH 13-24(REV.161831 76,©O G <br /> EH 14-26 <br />