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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 3 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> R (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instal!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 /> s M Size <br /> Job Address City Lot - <br /> Owner's Name Address Phone <br /> rQi <br /> Contractor_ ess License Na. Phone <br /> TYPE OF WEL P 'NEWME L ❑ WELL REPLACEMENT 171 DEST N ❑ <br /> g PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WE OTHER WELL PITS/SUMPS <br /> INTENDED USE ,. TYPE OF WELL PROBLEM AREA TRUCTION SPECIFICATIONS <br /> ❑ Industrial s❑:Open Bottom ❑ Mante Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑_Grav`el Pack.; racy Type of Casing Specifications <br /> ❑ Public.. ❑ Other `' ��❑ Delta-- Depth of Grout Seal Type of Grout <br /> ❑ Irrigation prox. Depth^�❑-Eastern *` Surface Seal Installed by (� <br /> Repair Work Done Type of Pump i . H.P. - State Work Done G <br /> Well Des n ❑ Well Diameter Sealing Material {top 50')' —� <br /> Depth I Filler Material {Below 501 <br /> i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION-0 DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> I/ available within 200 feet.) <br /> Installation will serve: Residencey Commercial_ Other <br /> r Number of living units:—I— Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. <br /> E] Type/Mfg Capacity No. Compartments <br /> i PKG. TREATMENT PLT. ❑ t. Method of Disposal <br /> a Distance to nearest: Well Foundation Property Line <br /> J I � <br /> LEACHING LINE No. &r Length of lines Total length/size <br /> FILTER BED ❑ )distance to nearest: WellFoundation i-ol Property Lin <br /> ' I <br /> I SEEPAGE PITS ❑ DeIptO'1e-,_2s3 ;96 Size Number <br /> UMP ❑ Distance to nearest: . Well Foundation Property Line <br /> DISPOSAL PONDS ❑ r <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 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 I r II wired ins i. ns. Complete rowing o rse side. f� <br /> Signed Title' Date: / <br /> # FO DEP MIENT USE ONLY <br /> Application Accepted by Date <br /> � 7 <br /> —�` Area <br /> Oltr Grout Inspection by &kBkDate Final Inspection by Dat • <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 AMOUNT;OUE AMOUNT REMITTED CASH I RECEIVED 0.Y DATE PfRMIT`N0. <br /> ` INFQ <br /> + EH 13-24(REV.1/85) `�7 <br /> EH 14-28 / n <br />