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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 /> PERMIT EXPIRES 3 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. �i <br /> Job Address 36 6 r City /�/� Lot Size PM <br /> Owner's Name o � Address <br /> Phone <br /> ContractorWRLL Address License . 30,31 Phone_9 0 S�, <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION �- <br /> PUMP INSTALLATI0 ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINEr <br /> FOUNDATION — X 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 /> l'1 Public ❑ Other F7 Delta Depth of Grout Seal Type of Grout---- <br /> 1 <br /> rout -1 1 Irrigation _Approx. Depth I i Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 _ <br /> TYPE OF SEPTIC WORK: NEW.INSTALLATION 11 REPAIR/ADDITION I 1 DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> 1 <br /> available within-200 feet.) <br /> Installation will serve: Residence Commercial w Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ V' <br /> Method of Disposal <br /> Distance to nearest: 7 .•Well;M..•.,�,-_ -Foundation­^^° , Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size- <br /> FILTER <br /> ength/size FILTER BED ❑ Distance to nearest: Well Foundation =•Property Line <br /> SEEPAGE PITS I I Depth Size <br /> Number s- <br /> SUMPS ❑ Distance to nearest: Well Foundation 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 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 /> empl ny person in such manner as to become subject to-workman's-compensation-laws-of-California."Contractor's hiring or sub-contracting signaturt;___� <br /> certifie t ollowing:"I ify 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 'fornia." 1 <br /> The app lica mu a!I r all r o S. amp drawing o reverse si e. <br /> Signe itle: Date: <br /> # fVR DEPARTMENT USE ONLY <br /> Application Accepted byDate Area U.Pit or Grout Inspection by Date Fina! Inspection by Date 3411 <br /> Additional Comments: <br /> ❑-Stk.-466-6781,,,.,,__❑..Lodi, 369-3621._,..;—❑ Manteca_823-7104_-_E]Tracy--835-6385. <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Sox 2009, Stk., CA 95201 <br /> IE .My.!OU!NQT DUE AMOUNT REMITTED RECEIVED 13Y DATE �PERMYIT'NO.MCASH <br /> +. H 3-21REV.iir5� 700 <br /> EH 14-26 — C <br />