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APPLICATION FOR PERMIT <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 r <br /> (Complete in Triplicate) application.This is <br /> �" made to the Sarr Joaquin Local Health District for a <br /> Permit to construct arta/or install and the Rules and'Regulatioons of he San Joaquin <br /> Application s hereby Ordinance No.549 for sewage or No. 1862 lar welllpurnp <br /> made in compliance with San Joaquin County P <br /> Local Health District. O` <br /> a4' Cil of Size <br /> Job Address' <br /> J_ Phone <br /> Address <br /> Owner's Na 1 r <br /> rise No Phon <br /> � <br /> ress <br /> Contractor WELL REPLACEMENT ❑ DESTR TION ❑ <br /> TYPE OF WELLY U P: NEW ELL ❑ OTHER ❑ <br /> SYSTEM REPAIR 13PUMP INSTALLATION ❑ DISPOSAL-FLD. •--� PROP. LINE- - - <br /> SEWER LINES _ --- ` ,� PITS/SUMPS; <br /> DISTANCE TO NEAREST: SEPTIC TANK -- -- AGRICULTURE WELL — OTHER WELL <br /> FOUNDATION <br /> INTENDED USE TYPE OF WELL PROB__ LEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Industrial Specifications <br /> Gravel Pack ❑ Tracy Type of Casing _ ^ti <br /> O Domestic/Private O Depth of Grout Seal Type of Gout {� <br /> (1 Other Cl Datta <br /> I"1 Public Surface Sea!Installed try <br /> I 1 Irrigation ,lAPprox. Depth 1-1 Eastern- -; State Work Done— <br /> Repair Work Done f O_ Type of Pump Baling Material Stop 501 <br /> ' Well Destruction O Well Diameter ---- <br /> Depth _ Filler erial (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAI DDITION I I DESTRUCTION I 1 availableo sep IsYs <br /> wthin 200 feet-1 <br /> if public sewer is ^ <br /> Installation will serve: Residence__ Commercial Other <br /> l Number of.living units: Number of bedrooms <br /> Water table depth— <br /> Character of soil to a depth of 3 feet: Capacit No. Compartments <br /> SEPTIC TANK ❑ Type/Mig f <br /> Method of Disposal <br /> PKG. TREATMENT PLT. 0 <br /> 1 �_ <br /> Distance to nearest: WeH/O foundation Property Line <br /> No. &-Length- <br /> en th1Iof lines Total length/size _ <br /> LEACHING LINE ,❑ , g Property Line _-- <br /> FILTER BED "�� Distance to nearest: Wel!/ f Foundation 1�1_LL_-- pe Y _ <br /> Siza Number <br /> SEEPAGE PITS I f Depth Pro Line _. <br /> SUMPS L) Distance to nearest: Well _ Foundation pain <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that t 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 Di3trict. rformance ai the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the pe nature <br /> employ any person in such manner as to become subject to workman's compensation laws of California.'"Contractor's hiring or sub-contracting sig <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued.I shah employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant ca r al _ (red inspect s. mplete drawing on reverse side. <br /> Signed X___ ' _ <br /> Title: _ Date: ` <br /> FOR DEPARTMENT USE ONLY <br /> Ylti>� t!, e Date �- f -85 Area_-- <br /> Application Accepted by <br /> Pt or Grout Inspection by <br /> 4 <br /> Date _ Final Inspectio»by Date <br /> Additional Comments: d �` <br /> ElStk 466-6781 El Lodi 369-3621 ❑ Manteca 823-7104 ElTracy 83 <br /> Applicant • Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.0- Box 2009, Stk., CA 95201 <br /> FEE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> AMOUNT DUE CASH r � <br /> INFO li <br /> ♦.E13 <br /> H 1}2{tREY.,i M 5! U C 31 (� T <br /> EH 14.76 <br />