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I <br /> ` x 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 1 YEAR FROM DATE ISSUED �. t <br /> rr a: (Complete in.Triplicate) <br /> i <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. THs 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 City Lot Size PM <br /> Owner's Name Address �^"'��� Phone <br /> Contractor Address License No. Phone_ <br /> TYPE OF WELL/PUM 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 /> ❑4ndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack, ❑ Tracy Type of Casing _ Specifications 11* <br /> ❑ Public ❑ Other ❑ 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 Sealing Material (top 501 <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION XNo septic system permitted if public sewer is <br /> available within 200 feet) <br /> Installation will serve: Residence Acommercial—' , Other <br /> i <br /> Number of living units:, Number of bedrooms i <br /> Character of soil.to-a depth of 3 feet: #° Water table depth <br /> SEPTIC TANKsrype/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.-❑ i '�..J +-r Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines r'""�" r W T Total length/size <br /> FILTER BED - ❑ ' Distance to nearest: z Well Foundation Property gLine <br /> SEEPAGE PITS_ ❑ Depth Size �fr: Number <br /> SUMPS ❑, Distance to nearest:- -Well 4. Foundation Property Line ' <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that t`he work vAf be done in"accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Jcaquirr 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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicap must call for all required inspections. Complete drawing on reverse side. <br /> Signed X r Title: Date: <br /> ! FOR DEPARTMENT USE ONLY ` <br /> Application Accepted by x Date9Y' Area <br /> Pit or Grout Inspection Date Final Inspection by <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tra4'-.835.6385 f l <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED IfK RECEIVED BY' PATE PERMIT NO. I <br /> + EH 13-24(REV.- /e 5)� � 9r+'f -� ' U� Q ! �7 f . <br /> 04.14-26 ( i <br />