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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 /> ti PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> IImation is <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 app <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 /> PM <br /> City Lot $IIB <br /> Job Address �� <br /> Phone <br /> Owner's Name Address <br /> License No. Phone 0 <br /> Contractor's Name <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST::SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> ) FOUNDATION <br /> AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPEOF WELL � PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom CD Manteca Dia. of Well Excavation <br /> Type of Casing Specifications <br /> [IDomestic/Private 1E] Gravel Pack O Tracy <br /> Depth of Grout Seel Type`f Grout <br /> [I Public i❑ Other <br /> �- ❑ Irrigation ° <br /> --Approx. Depth ❑"Eastern Surface Seal Installed by ^^ <br /> -� H P I State Work Done <br /> I Repair Work Done ❑ Type of Pump v , <br /> Well Destruction ❑ Well Diameter r i Sealing Material (top r <br /> Depth Filler Material (Bel 9 <br /> TYPE OF SEPTIC WORK: NEW INSTALLA N ❑ .•REPAIR/ADDITION DESTRUCTION ❑ avail ble within 20N am il feet <br /> feetKled if public sewer Is <br /> Installation will serve: R dance Commercial_ Other <br /> Number of living units: 7r Number of bedrooms I 'ti''Water table depth <br /> Character of soil to a.depth of 3 feet: No. Compartments <br /> LI . 1 <br /> SEPTIC TANK ' ❑ ;Type/Mfg, i ,rCapacity r Method of Disposal <br /> PKG. TREATMENT PLT. 13i Distance to nearest; Well Foundatibn Property Line <br /> a <br /> Total length/size <br /> LEACHING LINE 11 No.& Length of lines .A <br /> n Property Line <br /> ILTER BED "❑ ,Distance to nearest: .Well Foundatio <br /> 1r Size Number <br /> SEEPAGE PITS ❑ Depth _ Property Line <br /> SUMPS 'C1 Distance,to.n'�e�arest: Well Foundation <br /> DISPOSAL PONDS ❑ - ' t <br /> �-- at the work will be done In accordance with San Joaquin county ordinances, state laws, an <br /> I hereby certify that I have prepared this application and th <br /> n11es and regulations of the San Joaquin Local Health District. I shall n< <br /> 1 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, <br /> of <br /> emplo!'certifies(any person in the following: l certify that inh manner as tte performance of�-h)e work f09whkhthls compensationlaws <br /> 1 is issued,lfl hell employactors pawns subject to wring or orkman's comb ns <br /> I. <br /> Ai <br /> tion laws of California." <br /> he applicant must call for ajbreq ire d inspectio Complete drawing on reverse side. + .j� <br /> 1 �q " 'Title: 92 - o�'� Data: Ql <br /> Signed ) <br /> I FOR DEPARTMENT USE ONLY <br /> I 1 Area <br /> f <br /> Application Accepted by Date <br /> + �, — ` <br /> i 1 Final Inspection by Date <br /> .Pit or Grout Inspection by _ Date <br /> tAdditianal Comments: <br /> �. <br /> ❑ Stk 488-6781 t -t❑ Lodi 3883821 ❑,Manteca 823-7104 ❑ Tracy 83x63&5 <br /> Applicant- Return all copies to: Environmental Heslth Permit/Services 1601 E. Hazelton Ave., P.O. Box 21108, $ik.y CA 95201 <br /> CI I EIVED BY DATE I'� PERMRNO. ' <br /> FEE gMOUNT DUE AMOUNT RM <br /> EITTED CASH <br /> INFO <br /> 1 •EH t321NEY.10193 <br />