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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> aquin Local Health District for a permit to construct and/or install the work herein described. This application is f <br /> 1 <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 /> Application is hereby made to the San Jo <br /> Local Health District. +y } n <br /> S S, b5 City Lot Size I+ .9 � PM <br /> Job Address Q U 4 Y <br /> Owner' Address � i ] `� OST. L �p' ` we Phone <br /> s Name LL <br /> Address 1" License No. Phone <br /> K Contractor <br /> ~TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER D <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC,4TI6NS .i <br /> ❑ Industrial"'- �' -"" ""❑"Open Bottom ❑ Manteca dia. of Well Excavation <br /> Dia. of Well Casing <br /> Type of Casing- <br /> 1 <br /> asin Specifications -� <br /> LJ Domestic/Private LJg <br /> Gravel Pack ❑ Tracy <br /> 171 Delta Depth of Grout Seal r Type of Grout <br /> [I Public ❑ Other public C <br /> I I wigatian _.-Approx. Depth i I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump <br /> y P State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> ` Depth <br /> Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION--I 1. REPAIR/ADDITION l-I DESTRUCTION (Nailseptic syshintem <br /> permitted if public sewer is <br /> lavInstallation will serve: Residence _.— Commercial_ Other G <br /> Number of living units: Number oVbedrooms <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 V\ <br /> Q> <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <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: "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." 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 t it or a I equir nspections. Complete drawing on reverse side. <br /> Signed X <br /> • Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> '�' - '� � <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection b oat& <br /> Additional Comments: U - <br /> ❑ Stk 466-6781 If Lodi -3621 ■ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Silk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH 49 RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> �.EH 13-24{REV-1 i n 51 J ��./ _ <br /> EH 14-28 <br />