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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE,—_I ON AVE., STOCKTON, CA J <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. 1861 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> s F <br /> Job Address City Lot Size PM <br /> Owner's NameAddress r Phone <br /> 17 <br /> ContractorT -tel �C Address icense No.l/40's?'L1) Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 1' OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PLO. 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 /> kpomestic/Private ❑ Gravel Pack Cl Tracy Type of Casing F Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation �A 3' <br /> ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump ,A&Ae&— H.P. 1 State Work,Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic systerp 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 ¢o .y <br /> Character of soil to a depth of 3 feet: Water table depth 0 <br /> SEPTIC TANK ❑ Type/Mfg Capacity "No. Compartments G <br /> PKG. TREATMENT ALT. ❑ ` Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines - ✓ o.FTotel length/size„ y . <br /> FILTER BED ❑ Distance to nearest: Well ',Foundation ` Property Line <br /> SEEPAGE PITS ❑ Depth Size d Number <br /> SUMPS ❑ Distance to nearest: Well FoundationProperty Line <br /> FlDISPOSAL PONDS <br /> I hereby certify that I have prepared this applicafon and that thework will be done in accordancewith San Joaquin county ordinances, state laws,and,- <br /> rules and regulations of the San Joaquin Local Health District. : .r, I " _ <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 m st calljfpLall required inspections. Complete drawing on rverse de. �A <br /> Signed ` Title: -� Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date `)-2 <br /> `��� _ Area <br /> Pit or Grout inspection by Date Final Inspection by w Z!; <br /> Additional <br /> Additional Comments: ' <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 QfManteca 823-7104 ❑ Tracy 835-6385 - r <br /> Applicant- Return all copies to: Environmental Fr&lth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO.' <br /> • + Em 4(REV.1/s 5) <br /> EH 13-2 <br />