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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> l Telephone (209).466-6781 <br /> f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> : ,.. (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora nstall the_ A <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and he Rules and Regulatiork herein ns �SpapnrcJoaq is <br /> Local Health District. oaquin <br /> Job Address f` k <br /> J) �^ City lG Lot Size PM_ <br /> Owner's Name L 13�'Pf-M cn Address <br /> Phone -2 kZ 7 <br /> Contractor!�P Address <br /> License No. 3)ior; }-a Phone Z� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT. <br /> PUMP INSTALLATION ❑ DESTRUCTION ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK -� EWER LINES <br /> DISPOSAL FLD.�PROP. LiNE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL v r <br /> PiTS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO �. <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavatio Q <br /> Domestic/Private Gravel Pack Dia. of Well Casing !v <br /> ❑ Tracy Type of Casing <br /> ❑ Public <br /> 11 Other Specifications 1 <br /> eita Depth of Grout Seal <br /> ❑ Irrigation _/� Type of Grout �i'9".� <br /> --Approx. Depth Eastern Surface Seal Installed by qe/ 4 <br /> Repair Work Done ❑ Type of Pump H.P.Well Destruction ❑ Well Diameter State Work Done <br /> Sealing Material (top 501 r M <br /> Depth r Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> o.� <br /> Installation will serve:. Residence Commercial_ Other - °- .. _, T available within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Water table depth <br /> n <br /> PKG. TREATMENT PLT. E3Capacity No. Compariments ` <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines i <br /> FILTER BED - Total length/size <br /> ❑ Distance to nearest: Well Foundation Property Line { <br /> .I <br /> SEEPAGE PITS ❑ Depth Size <br /> SUMPSNumber <br /> ❑ Distance to nearest: Well e <br /> I! <br /> Foundation Property Line <br /> DISPOSAL PONDS ❑ i <br /> i <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 /> r 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 j <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 <br /> tion laws of California." permit is issued,I shall employ persons subject to workman's compensa- " <br /> The app <br /> lica u call for II re it inspections. Comple awing on verse side. <br /> a Signed <br /> Date: � <br /> FOR DEPARTMENT USE ONLY r <br /> r <br /> Application Accepted by <br /> fDate Li —r3 Area <br /> Pit or Grout Inspection by Date Fina! Ins 4 <br /> pection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 b ❑ Lodi 369 35ji ❑ Manteca 823 7104 ❑ Tracy $35 6385 <br /> 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 CK CK <br /> ECEIVED BY <br /> INFO CASk RDATE ?ER iT NO. <br /> + EH 13.24(REV.1/a5) U - <br /> EH 1428 <br />