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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON 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 /> Cit Lot Size PM <br /> Job Address !! = �` f y <br /> Owner's NameA <br /> Address �7� - Phone <br /> Contract i L cense No. 2 Phone <br /> Z-7 <br /> TYPE OF LL/P P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 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 ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> (`1 Public ❑ Other F Delta Depth of Grout Seal Type of Grout <br /> i I Irrigation Approx. Depth I I Eastern Surface Seal Installed 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 IM' REPAIR/ADDITION I I DESTRUCTION l I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence T Commercial_ Other <br /> Number of living units: . Number of bedrooms - <br /> Character of soil to a depth of 3 feet: Y/ Water table depth <br /> (1 SEPTIC TANK ❑ Type/Mfg Capacity r/ No. Compartments <br /> (�°} PKG. TREATMENT PLT. ❑ 1 Method o Dis o4al <br /> Distance to nearest: Well� un ationL ._._--..___ Property Line <br /> LEACHING LINE ❑ No. & Length of lines = f Total length/size <br /> FILTER BED ❑ Distance to nearest: Well[ P_ Foundation J Property Line <br /> SEEPAGE PITS 11 Depth Size _ Nulor <br /> SUMPS CI Distance to nearest: Well/_ _.5!foundation rr Property Line ___--_ <br /> DISPOSAL PONDS 1:1 <br /> i t/ <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 th nce 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 applicantallp I req 'ted inspe ions. 7omplete a ng on reverse side. <br /> r � <br /> Signed X �fitle: Date: 1 `� <br /> FOR DEPARTMENT USE ONLY <br /> ;i, <br /> ation Accepted by gg Date Area <br /> PitoGrout Inspection by ate Ynal inspection by Dat ra <br /> Additional Comments: <br /> ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 923-7104 ❑ 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 I CK CA$H FIECEIVED BY DATE PERMIT NO. <br /> INFO <br /> -EH 13-24(REV.i i n 51 2d <br /> EH 1429 <br />