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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> 1u �4 ^D (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 /> t 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 of Size PM <br /> Owner's Name Address 6 <br /> l <br /> Phone <br /> Contractor Address 0 <br /> r TYPE OF WELL/PUMP: NEW WELL ❑ License No.� � Phone <br /> r WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DJSTANCE.TO NEAREST:-SEPtIC TANK f e,3 OTHER ❑ <br /> -SEWERLINES rDISP,6SAL FLD. ��^ tp LIIVE! <br /> r FOUNDATION .AGRICULTURE WELL OTHER WELL <br /> PITS/SUMPS <br /> INTENDED USE ` TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />` D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> EJ Domestic/Private ❑ Gravel Pack Dia. of Well Casing — <br /> ❑ Tracy Type of Casing <br /> F1 Public «i n Other n Delta Specifications V <br /> Depth of Grout Seal Type of Grout <br /> I I Irrigation --Approx. Depth I 1 Eastern — <br /> d Surface Sea! Installed by <br /> Repair Work Done ❑ Type of Pump H p _ <br /> Well Destruction LJ Well Diameter F State Work Done_ <br /> Seating Material {top 501 <br /> Depth Filler Material {Below <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 17 REPAIR/ADDITION l 1 DESTRUCTION <br /> X(No'septic system permitted if public sewer is <br /> Installation will serve: Residence available within 200 feet.) <br /> Commercial s Other # t <br /> Number of living units: Number'ot,,bedrooms j <br /> Character of soil to a depth of 3 feet: } <br /> y No. Compartments <br /> SEPTIC TANK 4>e Type/Mfg j ` Water table depth <br /> ' / Capacit <br /> PKG%TREATMENT PLT. ❑ .-. <br /> i i Method ofrDisposal <br /> ' Distance to nearest: Well Foundation <br /> Property Line Koral <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size FILTER BED ❑ Distance to nearest: Well -Foundation Property LineSEEPAGE PITS f �i I Depth SizeNumberSUMPS L� Distance to nearest: Well Foundation Property Line xDISPOSAL PONDS f ❑I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin c� aw and ry c <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued„I shall not. y <br /> employ any person in such manner as to become subject to workman's compensation laws of California.”Contractor's hiring br,sub-contracting sign atuie <br /> certifies the following: ','I c�rtlfy that in the Performance of the work for which this permit is issued, I shall employ ' <br /> tion laws of California._' Vis_ p y persons subjed to workman's compensa <br /> `r The applicant must call f r all re uired inspections. Complete drawing on reverse side. ff I <br /> Signed <br /> F PARTMENT ONLY [� <br /> Application Accepted by <br /> i`� 3 <br /> .Date Area <br /> Pit or Grout Inspection by Date <br /> Finalslnspection by �1' DateOZ1�� <br /> Additional Comments: ` <br /> ❑ Stk 466-6781 <br /> EJ Lodi 369-3621 0 Manteca <br /> anteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to; Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK I <br /> INFO CASH RECEIVED BY DATE <br /> �ER�ilI1T�f1i0. <br /> + EH 1324 IREV. —a'V Ll�}�y �]/( (� <br /> EN 14.28-. Y-1�� <br /> u`"ymyri U <br /> 1 <br />