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APPLICATION FOR.PERMIT <br /> l SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL I ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> s { _ <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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. j <br /> Lam! <br /> y of Size PM <br /> ,� 6� � City <br /> Job Address .• � ` � <br /> a ss 3 �jp Phone <br /> Owner's Name `` dd' <br /> A '� Phone <br /> Contractor's Name icense No. j } <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT LJ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C OTHER ❑ <br /> _ <br /> DISTANCE TO NEAREST: SEPTIC TANK! SEWER LINES DISPOSAL FLD. PROP. LINE �� <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS � <br /> A. <br /> INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS Dia. of Well Casin "z <br /> ❑ Industrial C] Open Sottoin ❑ Manteca Dia. of Well Excavation <br /> Type of Casing,. Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack El Tracy Type of Grout <br /> ❑ Public LJ Other l El Delta Depth of Grout Seal yp <br /> Cy <br /> fIrrigatlon ---Approx. D�th ❑// E�as�tern Space Seal Installed by <br /> Type of Pump �,Le� * H.P. State Work Dane <br /> Repair Work Done ❑ (jf <br /> Well Destruction ❑ Well Diameter'i- Sealing Material (top 501 <br /> Depth I Filler Material iBelow 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION © alvailablseptic <br /> wi within 200 feettted if public sewer is a/1 <br /> Installation will serve: Residence Commercial_ Other <br /> i <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3.feet: 1 No. Compartments <br /> SEPTIC TANK t❑ Type/Mfg I Capacity Method of Disposal <br /> PKG. TREATMENT PLT. ❑ - t <br /> Distance to nearest: �Well Foundation Property Line <br /> Ff - <br /> Total length/size <br /> LEACHING LINE E:1 No. & Lenigth of lines a Line <br /> FILTER BED <br /> I'[] Distance to nearest: Well Property p rty <br />� RI . <br /> I <br /> Size Number <br /> SEEPAGE PITS ❑ Depth Property Line <br /> SUMPS 'E3; Distance to nearest: Well - Foundation p rty <br /> DISPOSAL PONDS ❑ <br /> 1 1 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 slgnature <br /> ' certifies the following:"I certify that in the F performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California."r s <br /> F The applicant lust c I for all r�uirei�nspe�ins. Completerdr/awing on reverse side. �r17!'�-1'ltle: Date: /Signed <br /> F EP 'ENT USE LY _ i <br /> �� Area <br /> Date <br /> Application Accepted by /, <br /> i . Date - <br /> r { Dat Final Inspection by <br /> Pit or Grout Inspection by _ - <br /> 41 — <br /> Additional Comments: i,. <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca ffi3 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 CK RECEIVED BY DATE f ERMIT•NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> ci- <br /> + EH 13.24 IREV,10!831 C - 2 a� <br /> t': EH 14.28 - F <br />