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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 7 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 Ryles and Regulations of the San Joaquin <br /> Local Health District. l <br /> Job Address Ci Lot Size 75)[,5n PM <br /> Owner's Name , Address Phone <br /> V�ppLU VV1 g <br /> Contractor T1 L ddress License No hone d+� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout (� <br /> ❑ Irrigation _Approx. Depth ❑ Eastern Surface Seal Installed by ,r <br /> Repair Work Dane ❑ Type of Pump H.P. State Work Done 0a <br /> -Well Destruction ❑ Well Diameter —.__. _:- Sealing Material (top 501 <br /> Depth `: `. Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIONLL-.DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) Q <br /> Installation will serve: Resi nce Commercial— Other G <br /> a r <br /> Number of living units: Number of b dr oms <br /> Character of soil to a depth of 3 feet: R E, Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Vie.. & Length of lines — 0 Total length/size <br /> FILTER SED ❑ Distance to ne t: ell Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS X—P49tance to nearest: Well�[Q_ Foundation � Property Line <br /> DISPOSAL PONDS ❑ R X4 <br /> I hereby certify that I have prepared this application and that the 4vork 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 uch manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature <br /> Nrtifies the followings 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 s ofklifornia,", <br /> Th plicall or II re ired in ction om a drawing on averse side. <br /> Signed Title:_ 1S Date: r <br /> \FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date �'�l ��� Area o <br /> Pit or Grout Inspection by Date j 'final Inspection by 4 <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24(REV. /I� � <br /> EH 14-26 J �/ <br />