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T � <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 , <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Health District for a <br /> n described.This <br /> cation is <br /> mpapolec n conmpliance withdSanoJoaqu n Coungty Ordinalnce No.549 for sewage or permit and/or install <br /> No. 1862 for well/pump and the Rules and IR Regulations of the San Joaquin <br /> Local Health District. j � R <br /> r( Lot Size c�i� �7� PM <br /> Job Address City <br /> ��� � f � Phone <br /> Owner's Name � (s�vAddress !:F� <br /> �rA�,s License No. der ( Phone <br /> Contractor ddres 7 `. <br /> TYPE OF WELL/ <br /> PUMP <br /> . NEW WELL <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PAIR;❑ OTHER <br /> ❑ <br /> PUMP INSTALLATION ( <br /> SYSTEM J r <br /> DISTANCE TO NEAREST: SEPTIC TANK �SEWER LINES DISPOSAL FLA. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL', OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL 'PROBLEM AREA CONSTRUCTION SPECIFICATIONS I <br /> LlIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Type of Casing Specifications <br /> !� <br /> Domestic/Private Gravel Pack [I Tracy YP 9 f > <br /> Other Cl Delta Depth of Grout Seal ���� Type of Grout <br /> F1 Public `� <br /> I 1-Irrigation ApProxl Depth I I Eastern Surface Seal Installed by <br /> Type of Pump � H.P. State Work Done _ <br /> Repair Work Done ❑ � <br /> Well Destruction ❑ Well Diameter �` 5ealing Material (top 501 -�V <br /> '` Filler Material (Below 50') <br /> Depth Cj <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 11'"DESTRUCT ION 1 1 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> b Installation will serye: Residence_ Commercial_1 Other <br /> Number of living units: Number of bedrooms -7 I <br /> Character of soil to a depth of 3 feet: .j Water table depth <br /> SEPTIC TANK O Type/Mfg —T Capacity No. Compartments. {( <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line I <br /> t <br /> c ` <br /> LEACHING LINE L1No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> i t ' <br /> SEEPAGE PITS l 1 Depth Size _ Number <br /> SUMPS El Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ _- _. ,- <br /> • 1 hereby certify that l 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 Di1trict. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit issued, I shall not <br /> of California."Contractor's hiring or sub contracting signature <br /> employ any person in such manner as to became subject to workman's compensation laws <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." a <br /> R <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> ORTMENT USE ONLY <br /> Application Accepted by <br /> Date Area <br /> Pit or Grout Inspection by <br /> ate S Final Inspection b. Date Y <br /> Additional Comments: <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CA H RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> a.EH 13-241REV.I/n 51 }� �� `jyry <br /> EH 14-28 <br />