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APPLICATION FQR PERMIT <br /> ' SAN JOAQUIN LOCAL HEALTH DISTRICT ` <br /> { <br /> • '� 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> all the work <br /> .This <br /> cation is <br /> madeinrcompliance with Sanade o I the Joaquin County Ordinance Non Joaquin Local .District549 for sewage or permit <br /> No. 1862 for weii/dpump and the Rules and(Regulations of he San Joaquin <br /> Local Health,District. <br /> Lot Size PM <br /> Job Address +✓ City <br /> (Address � � — Phone <br /> Owner's Name <br /> _5�L6nse No. Phone r <br /> Contractor's Name i <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEME ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK i <br /> X 1. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE-"-' f ,TYPE OF WELL., PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Dia. of Well Casing <br /> Industrial C1 Open Bottom ' ❑ Manteca Dia. of Well Excavation ` <br /> is � <br /> Type of CasingSpecifications , <br /> El Domestic/Private ❑ Gravel Pack C1 Tracy yp Type of Grout <br /> 1-1Public El Other I i❑ Deita Depth of Grout Seal 1 <br /> El Irrigation --Approx. Depth ❑.Eastern Surface Seal Installed by <br /> �. .' <br /> Repair Work Done [I Type of Pump H P. State Work Done -12- <br /> Well Destruction ❑ Well Diameter y Sealing Material (top 501 <br /> Depths I Filler Material (Below 501 <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> withirf 200'feet.) <br /> Installation will serve: ResidenceJ L commercial_ Other ' <br /> V <br /> Number of living units: Number of bedrooms <br /> t ! Water table depth <br /> Character of soil to a depth of 3 feet: ,' <br /> SEPTIC TANK ❑ Type/Mfg { I Capacity No. Compartments <br /> Method of Disposal <br /> I PKG. TREATMENT PLT. ❑ i �1 ^� <br /> Distance to nearest: We11, -Foundation Property Line <br /> LEACHING LINE .�' No. & Length of lines h Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> I � <br /> I SEEPAGE PITS ' Depth Size Number <br /> )Kr <br /> _ SUMPS 1-1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> EE 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: 11 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." Contractors 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 must call fo all req inspections. Cc late drawing on reverse side. <br /> ( Title: Date: <br /> Signed <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by G Yc'�'`� Date <br /> rea <br /> Pit Grout Inspection by <br /> e Lt-J� Final Inspection by Date:2i�nl <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> I - <br /> FEE CK RECEIVED BY DATE ;aMl . <br /> INFOA'+M-}iOUNT DUE AMOUNTEMITTED RCASH <br /> a EH 13-24(REV.10183) 1 90v .NO <br /> EH 1426 <br />