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APPLICATION FOR. PERMIT <br />r <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1 1601 E. HAZE T ON AVE., STOCKTON, CA <br />'! l Telephone (209) 466.6789 <br />PERMIT EXPIRES'l YEAR FROM DATE ISSUED <br />(Complete in Triplicate),, x <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/pump and the Rules and Regulations of the San Joaquin <br />Local Health District.... <br />rf <br />Job Address ®0City Lot Size D M <br />Owner's Name Address} <br />.Phone <br />Contractor's Contractor's <br />TYPE OF WELL/PUMP: " NEW WELL ❑ <br />DISTANCE TO NEAREST: <br />INTENDED USE <br />❑ Industrial <br />❑ Domestic/ Private <br />❑ Public <br />❑ Irrigation <br />Repair Work Done ❑ <br />Well Destruction ❑ <br />PUMP INSTALLATION ❑ <br />SEPTIC TANK <br />FOUNDATION <br />No. <br />WELL REPLACEMENT <br />SYSTEM REPAIR <br />SEWER LINES <br />AGRICULTURE WELL <br />❑ DESTRUCTION <br />❑ ;OTHER <br />DISPOSAL;FLD. <br />OTHER WEWZht <br />TYPE OF WELL <br />PROBLEMAREA 1CONSTRUCTION SPECIFICATIONS <br />❑ Open Bottom <br />❑Manteca s Dia. of Well Excavation r <br />C1 Gravel Pack! <br />❑`Tracy * Type of Casing <br />❑ Other❑ <br />Delta Depth of Grout Seal <br />__._ Approx. Depth ❑ EasternSurface Seal Installed by <br />Type of Pump <br />W.P. State Work Done <br />Well Diameter <br />_ <br />Sealing Material {top 50') j <br />Depth -� <br />i �ilEer-Mlaterial.JSelauv -- �s <br />Phone 4�__.&v <br />PROP. LINE <br />PITS/SUMPS <br />Dia of Well Casing <br />,1 <br />Specifications <br />Type of Grout <br />TYPE OF SEPTIC WORK: NEIN INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br />•.€ available within 240 feet.] <br />Installation willsetve: Residence �kCommercial� Other <br />Number of living units: Number: of bedrooms <br />Character of soil to a depth of 3 feet: f Water table depth <br />SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br />PKG. TREATMENT PLT. ❑ 1' <br />E k <br />i r <br />Distance to nearest: <br />t <br />AA Method of Disposal . <br />Well Foundation Property Line f �� <br />t§EACHING LINE No. & Length of lines�--- Tota! length/size,/ <br />FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br />ti <br />SEEPAGE PITS )it DepthSize Number <br />SUMPS ❑ Distance to nearest: Well!� Foundations 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-icensed 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 must call for alf r fired inspections. C plate drawing on rse side. <br />t• �j <br />Signed Title: <br />Date: <br />7�LFOR DEPARTMENT USE ONLY <br />Application Accepted by Date I 0" q - tz <br />9 <br />Pit or Grout Inspection by Date Final Inspection by <br />ra <br />Date <br />Additional Comments: 1 11 <br />U Stk 466-6761 ❑ Lodi 369-3621] ❑ Manteca 823-7104 ❑ Tracy 835-8385 <br />Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2409, Stk., CA 95201 <br />FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"N0, <br />INFO CASH <br />+ EH 1324 [REV. 10!831rr <br />EH 14-25 Lla C3 O ���/ %Lj <br />N <br />