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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 /> r <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 1/ Cityot Size PM <br /> Owner's Name Addresse2,.Ce2 �.,� Phone <br /> 14g; Phone <br /> r�S�� <br /> Contractor's Name �� License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION W /?&_1ZW_&ft�9TEM 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 <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 1 ; <br /> ❑ irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by f k <br /> Repair Work Done ❑ Type of Pump - H.P. -? State Work Done P / <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 1% A � <br /> Depth Filler Material (Below 501 `v I i li <br /> I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if pubfib sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number' <br /> 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 1 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size Gtr <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Lines P <br /> SEEPAGE PITS ❑ Depth Size Number <br /> i <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line R <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 ordlnances,'�state law's, and <br /> r <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."Contracto is 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 applicant must call for all required inspections. Complete drawing on reverse si <br /> Signed , _ Title: Date: <br /> FOR DEPARTMENT USE ONLY,�S`f E "RC2 �a14 <br /> Application Accepted by f/V �° 'Date <br /> ea <br /> Pit or Grout Inspection by Date final Inspection by - Date <br /> Additional Comments: - — <br /> ❑ Stk 46&6781 . - ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601-E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 } <br /> I <br /> FEE AMOUNT DUE ' AMOUNT ACMIT TED CASH <br /> ~� RECEN ED BY DATE PERMIT"NO. <br /> INFO <br /> + EH13-241REV.14/63) ��`7—� <br /> EH 14-26 7 <br /> I J <br />