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f <br /> APPLICATION FOR PERMIT <br /> u 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 <br /> (Complete in Triplicate) <br /> I 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 /> l Job Address �. <br /> ty OCJrUI@^t.ti Lot Size PM <br /> 1 <br /> Owner's Name Q Address <br /> Phone <br /> Con tracAddressLi <br /> E p <br /> cense No. [ ? Phone <br /> TYPE OF WELL/PUMP: 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 /> ❑ Industrial ❑ Open Bottom ❑ Manteca. "�Dia..of l+Vel l`Ezcavatioyrf—i Dia. of Well Casing <br /> E] Domestic/Private C] Gravel Pack ❑ Tracy Type of Casing k <br /> Specifications <br /> f 1 Public n Other Grout... fl Delta: Depth of Grout Sea! <br /> Type of Grout <br /> I I Irrigation A rox.,:De Depth t I Eastern i °rte _ <br /> — pP P Surface Seal Installed by �� <br /> Repair Work Done ❑ Type of Pump.. H.P. States'Work.Done k-" <br /> Well Destruction ❑ Well Diameterr+4•. i Sealing Material (top-50'.I <br /> DepthFiller Material (Below 50')-- <br /> TYPE <br /> 0')+TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION l I DESTRUCTION` f (No septic system Permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve; Residence Commercial Other <br /> Number of living units: i Number of bedrooms <br /> Character of soil to a depth of 3 feet:I Water table depth } <br /> SEPTIC TANK ❑ Type/Mfg' Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ f Method of Disposal - I <br /> r� <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length–& Total length/size _ <br /> FILTER BED ❑ Distance to nearest: y Well Foundation _r <br /> .� Property Line <br /> SEEPAGE PITS I I Depth I Size Number l <br /> SUMPS - ✓ <br /> ❑ Distance to nearest: Well Foundation - Property Line <br /> DISPOSAL PONDS ❑ { + <br /> I her 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 JoaquinjLocal Health District. s <br /> Home owner or licensed agent's signature certifies the following: + " - r <br /> '9 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 1 <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ parsons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant us call for all required inspections. Complete drawing on r rse side. <br /> Signed X Title: r� I � <br /> --Date:----Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date a�i <br /> f j <br /> Additional Comments:. _ <br /> ❑ Stk 466-6781 F ❑ Lodi -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, S1k., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO CK RECEIVED 9Y DATE PERMIT'NO. <br /> . EH <br /> 13-24(REV.1inse <br />