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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> w 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 <br /> City Lot Size PM <br /> Owner's Name <br /> Address <br /> Phone <br /> Contractor 17�9 <br /> s ansa No. <br /> TYPE OF Will/PU P: NEW WELL ❑ Phone <br /> WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST; SEPTIC TANKOTHER ❑ <br /> -•�� SEWER LINES �__�. DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL <br /> OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Man tao ~ <br /> Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T <br /> M Public ypa of Casing . Specifications <br /> Cl Other ❑ Delta Depth of Grout Seal — <br /> i f Irrigation —.-Approx. Depth I 1 EasternType of Grout <br /> Repair Work Done ❑ Type of Pump <br /> Well destruction ❑ Well Diameter Surface Seal Installed by <br /> H.P. State Work Done <br /> Sealing Material (top 501 <br /> Depth Filler Material ISelow <br /> TYPE Of SEPTIC WORK; NEW INSTALLATION 17 REPAIR/ADDITION I 1 ESTRUCTiON I 1 1-11,15 <br /> No septic system permitted if public sewer is <br /> Installation will serve: Residence available within 200 feet.l <br /> Commercial <br /> Number of living units: Number of bedrooms_49== <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type Water table depth <br /> /Mfg acity <br /> PKG. TREATMENT PLT. ❑ CapNo. Compartments <br /> Distance to nearest: Well_ / Method of Disposal <br /> Foundation_ �_ Property Line c <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BEDr Total length/size <br /> ❑ Distance to nearest: WeltJill_ )Foundation <br /> -f- Property Line a <br /> SEEPAGE PITS Depth .- Size <br /> SUMPSNumber <br /> LI Distance to nearest: Weil 4-611 Foundation <br /> DISPOSAL PONDS ❑ Pro Fly Line <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." Contractors hiring or suh-contracting signature <br /> certifies the following: "I certify that in the rformance 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 applicant s c r all r r d i ctions. Complete drawing onIre rse side. f <br /> Signed X Title: <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by — '� <br /> Date Area <br /> Pit or Grout Inspecti Date <br /> Final Inspection by Date - Q <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 <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 <br /> INFO CASH RECEIVED BY DATE PERMIT'NO. <br />. EH 13-24 11F i x 5l *1/.�' �� <br /> EH 14.28 V ��h��� R-7-20 <br />