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APPLICATION FOR PERMIT <br /> SAN JOAQUiNwLOCAL.HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE:, STOCKTON, CA <br /> Telephone(209) 466-6781 <br /> PERMIT EXPIRES'? YEAR FROM DATE ISSUED , <br /> t, <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 Address Phone <br /> Contractor f/ �.f� Address 70 /✓I T�� License No. Phone $7� <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 FLD. 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 v� <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other O Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation, ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter `^rim—^ ­_Sealing"Material"1top 50'I <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system <br /> permitted if public sewer is <br /> available within 200 feet.) <br /> ,4nstallation will serve: Residence Commercial_ Other <br /> r. <br /> Number of living units:_/__ Number of bedrooms 3 <br /> Character of soil to a depth of 3 feet: 3 Water table depth <br /> SEPT(CTA•NK- ❑,?'`Type/Mfg Capacity No. Compartments <br /> ,PKG. TREATMENT PLT. ❑ f <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE CNo. & Length of lines 14, <br /> ' Total length/size <br /> FILTER BED ❑_ Distance to nearest) W <br /> . � I _� � ell 'Foundation 1,iM�:� Property Line <br /> + 1 A; <br /> SEEPAGE PITS ❑! Depth Size <br /> 4. f Number <br /> SUMPS ❑ 'Distance to nearest:`qNo Weli�' �)Foundation` Property Line <br /> DISPOSAL PONDS ❑ I <br /> 1 <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-Distiict.�z_ _ J. .� i <br /> Home owner or licensed agent's signature certifies the following: "I cerdfy that in thejperformance 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 following:"I certify that in the performance,af the work for which this permit is issued, I shall employ persons subject to workman's compensa <br /> tion laws of California." a �' i z.. <br /> The applicant must call f r all requir inspections. Complete-drawing;on reverse side. <br /> �• --. . <br /> Signed <br /> Date' <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Date rea <br /> 3� --�7 06 <br /> _ A <br /> Pit or Grout Inspection by !! Date Final Inspection by_ 1(�Q / Date � ts� <br /> a' <br /> Additional Comments: 4 <br /> ❑ Stk 466-6781 1 C1 Lodi 369-3621 ❑ Mantecay 823-7104 ❑ Tracy <br /> AppliJcant- Return all copies to: EnvironmentalCHealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 7.003,Stk., CA 952Q1 <br /> FEE AMOUNT DUE - AMOUNT REMITTED CK <br /> CARECEIVED BY DATE PERMIT`NO. <br /> INFO SH <br /> EM 13-24 <br />• + 1RE .t%a5� <br /> EH 1429 <br /> 7-47 �7 �7 <br />