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s <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA 0�s <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 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. . <br /> Job Address -' r- City' Lot Size V ,\�� <br /> PM <br /> i <br /> Owner's Name `�'ti.l� O�'� Address 2 �Q <br /> Phone <br /> . f <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑, LL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ YSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DiSD. PROP. LINE <br /> FOUNDATION AGRICULTURE LL OT POSA ELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTR CTIO ECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom Li Manteca Dia. ofT xcavation Dia. of Well Casing <br /> CJ Domestic/Private ❑ Gravel Pack ❑ Tracy T of Casing. Specifications (� <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 1 '� <br /> ❑ Irrigation _"__Approx. Depth ❑ Easter Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done ; <br /> Well Destruction D. Well Diameter Sealing Material(top 501 <br /> Depth Filler Material {Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 171REPAIR/ADDITION EJDESTRUCT ( septic system permitted if public sewer is <br /> ailable within 200 feet.) <br /> Installation will serve: Residence_ •Commercial_ 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. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> i <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size. 1" Number <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 /> 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 of the work for which this permit is issued,l shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> T p ust call for all requiied inspections, Complete drawing on reverse side. <br /> Signed ��� Title: <br /> Date: ; <br /> FOR DE NT UP ONLY . ' ,r• /.+ .• 4 <br /> Application Accepted by Date —� Area (J-3 <br /> Pit or Grout Inspection by Date Final Inspection by Dat,3-��17 <br /> Additional Comments: <br /> ❑ Stk 466-Ml ❑ Lodi5W3021 Cl Manteca 41040 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 /> fINFO <br /> EAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMITNo. <br /> hy+ ER13-24IHEV.1iss1 '�� + '�� ff,Ls/ �J-', �. !""/ <br />