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I APPLICATION FOR PERMIT <br /> SAN JOAQUIN-LOCAL HEALTH DISTRICT f �/�V' <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> I Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Tripficate) <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 /> l th San Joaquin county Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> made in compliance wi <br /> Local Health Districts < <br /> 71�., / 0 <br /> Job Address .�1f IF-�,���! CityLot Size PM - <br /> f t•E <br /> I Owner's Name <br /> Address Phone <br /> � 6l <br /> l �r1� mP,7,iSu Address License Nn...1LC�ll�JlPhane� <br /> ontractor <br /> TYPE OF WELL/PUMP: :NEW WELL WELL REPLACEMENT ❑ DESTRUCTION LJPUMP INSTALLATION 2-/ SYSTEM REPAIR ❑ OTHER 11 <br /> 1 DISPOSAL FLD ROP. LINE <br /> k DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES � yy.��,,��__ <br /> FOUNDATION AGRICULTURE WELL J /1.&THER WELL PITS/SUMPS <br /> } INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casi <br /> r Type of Casing <br /> � Specificati i <br /> i�omesticIPrivate ravel Pack ❑ Tracy yP g <br /> Other Cl Delta Depth of Grout Seal <br /> f'] Public Type of rout <br /> f-I Ot <br /> I I Irrigation Approx. DeRt1_ ilE <br /> tern Suce Seal Installed by <br /> 11 \`I— If/[ H P State Work Done <br /> Repair Work Done L�-'Type of Pump <br /> Well Destruction CJ Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRIADDITION L1 DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> }} Installation will serve: Residence Commercial Other <br /> 1. <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 <br /> Capacity - No. Compartments t <br /> PKG. TREATMENT PLT. EJMethod of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ElNo. R Length of lines Total length/size <br /> r <br /> FILTER BED ❑ Distance to clearest: Well Foundation Property Line <br /> € SEEPAGE PITS 11 Depth j Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property.Line <br /> DISPOSAL PONDS .❑ <br /> I hereby certify that I havi?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 /> Homeowner 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 /> r The applica st caN for all re red inspections. Complete drawing on reverse side. <br /> Signed Title: r Date: <br /> O DEPARTMENT USE ONLY <br /> I Application Accepted by l Date — Area O <br /> fJ'�_ � � � Date <br /> Pit or Grout Inspection by/ � Date ��— Final Inspection by <br /> I Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 n <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., GA 95201 <br /> 6 FEE MOUNT DUE AMOUNT REMITTED Cx RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> ♦ <br /> EH 13-24 tREV.tins/ D 5 <� ��/�� '} <br /> EH 14-26 <br /> r <br />