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APPLICATION FOR PERMIT lVoo ArkAr <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 <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/ ump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address r <br /> City Lot Size PM <br /> S� <br /> r Owner's Name Address a <br /> Phone ! T <br /> Contractor cess 9? - <br /> License 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. <br /> FOUNDATION PROP. LINE <br /> 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 1 <br /> ❑ Domestic/Private ❑ Grave! Pack Dia. of Well Casing \ <br /> ❑ Tracy Type of Casing <br /> f'l Public C7 Other Specifications <br /> fl Delta depth of Grout Seal <br /> I i Irri ation Type of Grout <br /> g —.Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H p <br /> State Work Done_ t <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth - Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLAT}ON I REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewev is <br /> Installation will serve: Residence�;/ Commercial_ available within 200 feet.) <br /> Other 4 <br /> Number of living units; Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK Water table depth <br /> ❑ TypelMfg Capacity {�} No. Compartments M <br /> PKG, TREATMENT PLT. ❑ <br /> y� Method oLpispo al c <br /> Distance to nearest: Well f)O Foundation �_(J/[� Property Line <br /> LEACHING LINE ' <br /> ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Wellr' <br /> Q— Foundation ,Z— _ Property Line <br /> SEEPAGE PITS I I Depth Size <br /> _ mbar <br /> SUMPS <br /> CI Distance to nearest: We!! + <br /> Foundation Line S <br /> Property LiI <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 ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: r <br /> !o an ��I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ Y y 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 applicant usi cat)for aluired ins tions. Complete drawing on reverse side. <br /> Signed X <br /> Title: <br /> Date: <br /> FOR DEPARTMENT USE 0" <br /> Application Accepted by K `� <br /> Date Area <br /> It <br /> r Grout Inspection by Date i <br /> • Final Inspection by <br /> ditional Comments: �— <br /> Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.❑Hazelt n 3Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO ^ CASH RECEIVED BY DATE PERMIT*NO. <br /> + EH 13-24{REV,tinsr <br /> EH 11-28 <br />