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e <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> 1 � <br /> Job Addres 1 City Lot Size PM <br /> Owner' amZeAD Address n Phone <br /> �QR?_E' �,Jdl 4`t �m Z d Phone <br /> Confrac Addres License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ( SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> CDodustrial ❑ Open Bottom LJManteca Dia. of Well Excavation Dia. of Well Casing ` <br /> mesticf Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1 <br /> r'1 Public [ Other C1 Delta Depth of Grout Seal Type of Grout <br /> I 1 Irrigation --Approx. "h I 1 Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump k-13 H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material atop 50'1 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) C <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 /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I 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 shalt 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 f owing: "I certify that inUin .n <br /> 'mance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion iaw5 of C lifornia." <br /> The applic t us call or II a ires. Complete drawingon r e e side. <br /> Signed X 1 Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date '5114—l" Area <br /> Pit or Grout Inspection by Date Final Inspection by Date .60 <br /> 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 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK if RECEIVED BY DATE PER 'NO. <br /> ♦.EH13-24{REV.riHe� � <br /> EH 14-26 <br />