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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT CEIVE <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 J U L 2 <br /> PERMIT EXPIRES T YEAR FROM DATE ISSUED NVIRONM t <br /> (Complete in Triplicate) PERMI������ wc�EA��� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein descri6 d. his 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 4City�..� Lot Size PM <br /> Owner's Name © Address s:— <br /> Phone �Q <br /> Contractor&V {_ Address +4 License No. lA Phone <br /> 464rL31 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Nt- 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 1 0 Open Bottom ❑ Manieca Dia" of Well Excavation Dia. of Well Casing <br /> )Cbomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1`1 Public Ll Other F1 Delta Depth of Grout.Seal Type of Grout <br /> ! I Irrigation --Approx. Depth I I Eastern Surface Seal lnstalled by <br /> Repair Work Done ❑ Type of Pump IIC[a_ H.P, State Work Done_ {li\ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') r <br /> Depth_ Filler Material (Below 501 _ t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR)ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is {�, e <br /> available..withinlp0 feet.► <br /> V <br /> Installation will slerve: Residence_ Commercial .._ Other <br /> NumberofLiving units: Number of bedrooms <br /> Character of soil to a depth of 3 feet. Water table depth <br /> SEPTIC"TANK 4 ❑ Type/Mfg Capacity No. Compartments <br /> ti PKG. TREATMENT-P-L�.0- -.- --. �ti TM Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> :I <br /> LEACHING LINE CI No-& Length of lines - Y -Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property-Lirie <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS 4, --D •Dista nee to-nearest= ' ^ Well•-�, 'Poundation 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 Dr'%trict. <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 folio : "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 Cali orni I <br /> The a$ call for all requ"a inspecUo Co lets drawing on r ve a ide. <br /> Signed X Title: 44 <br /> Date: <br /> F RD ARTME SE ONLY p <br /> Date <br /> Application Accepted by � �/ b Area -tea s �i <br /> Pit or Grout Inspection by Date Final tnspection.by� Date <br /> Additional Comments: <br /> ❑ Silk 466-6781 ❑ Lodi 369-3621 C1 Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMITN0. <br /> INFO CASH <br /> +.EH 13-24 IgEV.i/n 51 // <br /> (a <br /> EH 14-26 <br />