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S <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL 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 /> Job Address Ir <br /> " City Lot Size PM <br /> Owner's Name Address S <br /> Phone - <br /> Contractor Address <br /> TYPE OF WELL/PUMP: NEW WELL ❑ License No. Phone <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATfON ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL <br /> OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL ,PROBLEM AREA CONSTRUCTION SPECIFICATIONS- <br /> El Industria! ❑ Open Bottom .' ❑ Manteca Dia. of Well Excavation <br /> C1 Domestic/ Tracy Domestic/Private ❑ Gravel Pack A Dia. of Well Casing <br /> Type of Casing <br /> IJ Public ❑ Other ❑ Delta Specifications <br /> Depth of Grout Seal Type of Grout {' <br /> 171Irrigation —rQpprox. Depth ❑ Eastern Surface Seal Installed by W <br /> Repair Work Done ❑ Type of Pump H P <br /> Well Destruction ❑ Well DiameterState Work Done <br /> Sealing Material (top 50') , <br /> Depth Filler Material (below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permittAP"r <br /> available within 200 feet.! 4 <br /> Installation will serve: Residence— Commercial i Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK F-1 table depth <br /> ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ � � <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line111 <br /> LEACHING LINE ❑ No. & Length of lines FILTER BEp Total length/si � <br /> ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS ❑ Depth Size <br /> SUMPS ❑ DiNumber <br /> Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ Property Line <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 followin <br /> em Io an 9: ""I certify that in the performance of the work for which this permit is issued, I shall not <br /> ploy y person in such manner as to become subiect to workman's compensation laws of California."Contractor's hiring or sub-contracting signature f <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 for all required inspections. Complete drawing on reverse side. <br /> Signed ' <br /> Title: Date: <br /> FOR DEPARTMEN�USE NLY <br /> Application Accepted byZZ—Date Q <br /> 4 Area D <br /> Pit or Grout Inspection by er' 's <br /> Date Final Inspection by <br /> Additional Comments; a trc� To CO-o. r- - _ <br /> ❑ Stk 466-6781 �' <br /> ❑ Lodi 369-3621 C Ma tete 623 7104 ❑ Tracy <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE gMOUNT DUE AMOUNT REMITTED K <br /> INFO I <br /> C RECEIVED 8Y DATE PERMIT'NO. <br /> + EH 1324(REV.k/as) •'''� //� <br /> EH 14-28 <br /> 3 <br />