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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 /> 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. <br /> Job Address ���� ����� City. :�� /Lot Size ` , ���` PM <br /> Owner's Name Address / S(1720 Phone <br /> Contractor d Address��� /L/ C�/U�L.iti _ --__- License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ LL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE DISP FLD. PROP. LINE 1 <br /> FOUNDATION AGRICULTURE LL HER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONST>0GON SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Di . of Wel xcavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout S I Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Ea rn Surface Seal Installs by <br /> Repair Work Done ❑ Type of Pump H.P. tate Work Done <br /> Well Destruction ❑ Well Diamete Sealing Material (top 60'1 <br /> Depth Filler Material (Below 501 <br /> I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION K(No septic system permitted if public sewer is <br /> available within 200 feet.l <br /> Installation will serve: Residence_ Commercial_ Other <br /> a I <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK X Type/Mfg CapacityCJ00. No. Compartments <br /> PKG. TREATMENT PLT. ❑ 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 ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <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 /> 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 /> app nt must call f r 11 ins ct' s. Complete drawing on reverse side. ®�7 <br /> Signed Title: Date: f3 4 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date —�� Area <br /> Pit or Grout Inspection y Date Fina! Inspection Date�� <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. <br /> INFO CASH r of <br /> + EH 13-24(REV.ties) ��'�� <br /> EH 14-26 c.� / / <br />