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APPLICATION FOR PERMIT , <br /> t <br /> SAN JOAQUIN LOCAL"HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 4209} 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 Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> .r <br /> Job Address <br /> Wil= City Lot Size PM 1 <br /> Owner's Name Address"N Oi l le _ &eA"a Phone 2 ^ <br /> Contractor Address/ —y License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 21" OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ` DISPOSAL FLD. 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 /> J;� Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing i Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done F Type of Pump— H.P. 3 f State Work Do le <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 _4_111C <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial�" Other , <br /> Number of living units: ? `Number of bedrooms ° <br /> Character of soil to a depth of Veet: Water table depth <br /> SEPTIC TANK Ll Type/Mfg Capacity . No. Compartments <br /> PKG. TREATMENT PLT. ❑ + Method of Disposal <br /> l j <br /> Distance to nearest: Well Foundation .Property Line <br /> 1 Ir -..e . . <br /> LEACHING LINE ❑ No. &Length of lines Total length/size " r <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPSCl Distance to nearest: .Well i Foundation Property Line <br /> I DISPOSAL PONDS ❑ <br /> ! - <br /> I hereby certify that 1 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, 1 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 st I! all required inspections. Complete drawing on r side. <br /> ' Signed Title: ( Date: F� <br /> OR DEPARTMENT USE ONLY M ;} <br /> Application.Accepted y Date <br /> 1 <br /> Pit or Grout Inspectio y Date + Final Inspection by / IQ?qvpj <br /> Additional Comments: d <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 I <br /> FEE AMOUNT DUE . AMOUNT REMITTED C K H RECEIVED BY DATE NO.' Z <br /> INFO <br /> I + EH 13-24(REV.1/85) SfUo <br /> EH 14-26 <br />