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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 /> 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. 1852 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. �! , <br /> Job Address ru City Lot Size PM <br /> Owner's Name Address Phone <br /> c i F. r <br /> Contractor's Name �'�License No. �_? � �� s Phone <br /> Cie <br /> TYPE OF WELL/PUMP: -NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION l 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 Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pumrp Ae� H.P._ 1 �". State Work Done G <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 <br /> Depth I Filler Material {Below 501 <br /> I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION C7 {No septic system permitted if public sewer is <br /> 1 available within 200 feet.] <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg - Capacity No. Compartments <br /> r PKG. TREATMENT PLT. ❑ I Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> I � <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED © Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth ' Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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." I <br /> The applicant must ca for all requie inspections. Complete drawing on reverse side. -� <br /> Signed .n -_ — Title:— -�- -_ Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Data Area <br /> Pit or Grout Inspection by Date �Final.Inspection by Date <br /> Additional Comments: — <br /> ❑ Stk 466-6781 ❑ odi 369-3621 ❑ M taco /b23-7144 ❑ Tra6y <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 REMITTED CASH RECEIVED BY DATE PERMIT"NO. <br /> INFO <br /> + EH 13-24[REV.10/831 71z� —Zs -r� <br /> EH 1425 �� , <br />