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*" = APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> i Telephone (209) 466-6781 <br /> (PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I (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 /> madeincompliance 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''He'ilth District <br /> SYk <br /> rY�{rilrs ',r '�-1 <br /> l37 >;c�' l� cue e J : <br /> Job Address - City Lot Size. PM <br /> Owner's Name Q-f•'�1�� -�' S��L Address l­aPhone <br /> Contractor Address &!4��� �6�eLIlcense No. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL -WELL REPLACEMENT ❑ DESTRUCTION ❑' <br /> PUMP INSTALLATION L7 SYSTEM REPAIR ❑ OTHER ❑ i <br /> DISTANCE TO NEAREST: SEPTIC TANK /M'* SEWER LINES DISPOSAL FLD. 401+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 /> yDomestic/Private Y Gravel Pack Y Tracy Type of Casing_ Air. � Specifications <br /> f Public ❑ Other H Delta Depth of Grout Seal Type of Grout GL <br /> I I Irrigation —Approx.Depth I 1 Eastern ` Surface Seal Installed by— <br /> Repair <br /> y Repair Work Done LJType of Pumpr H.P. State Work Done <br /> Well Destruction ❑ Well Diameter _. Sealing Material (top 50'1 <br /> Depth 'i 1Filler Material (Below 50') <br /> � I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION l I DESTRUCTION l I INo septic system permitted if public sewer is 0 <br /> sl available within 200 feet.i <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 I Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ i Method of Disposal <br /> Distance tor nearest: Well Foundation .. Property Line <br /> I <br /> SII <br /> f LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> I <br /> SEEPAGE PITS I 1 Depth t Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ t --- -- <br /> I hereby certify that I have prepared thWapplication and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquiri 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 applicust call for all requir inspections. Comple a drawing on reverse side. <br /> Signed X itle: Date: <br /> DEPARTMENT USE ONLY <br /> Application Accepted by Date r Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> I Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED I CK 11 RECEIVED BY DATE PERMITNO. <br /> INFO L{,�� C�AS/H� ` <br /> . EH 13-24 1AEV.t/H 57 goo�� <br /> EH 11-29 <br />