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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT Q­� <br /> >r� <br /> 1601 E. WAZEL TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) cam' � ;�,. <br /> cribed;yThis a pli anon is <br /> and the Rules an alio ns of tha:'San Joaquin <br /> Application is hereby made to the San Joaquin Local Health•District for a permit to construct and/or install the work her <br /> made a compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welllpump Y <br /> Local Health District. L <br /> City <br /> 1 Lot Size PM <br /> Job Address 2_ <br /> Phone <br /> G Address <br /> owner's Name <br /> 3 r License No. yds—Phone <br /> Address <br /> k Contfac46LL/ <br /> WELL REPLACE ENT ❑ DESTRUCTION ❑ <br /> F TYPE OPUMP:�ONEW�WELL ❑ OTHER ❑ <br /> SYSTEM REPAIR ;� <br /> PUMP INSTALLATION X DISPOSAL FLD. PROP. LINE <br /> SEWER LINES —_—� PITS/SUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> _ SEWER AGRICULTURE WELL OTHER WELL <br /> FOUNDATION �� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of-Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> D Industrial Specifications <br /> ❑ Gravel Pack ❑ Tracy Type of Casing <br /> f�$ Domestic/Private Type of Grout <br /> k Cl Other n Delta Depth of Grout Seal <br /> ["I Public Surface Seal Installed by <br /> I I Irrigation Ac.Appx, Depth I Eastern State Work Done <br /> ' H.P,- <br /> Repair Work Done ❑ Type o! Pump Sealing Material [top 50'1 <br /> Well Destruction F1 Well Diameter <br /> Depth # Filler Mat11 erial {BelOW 501 <br /> available within 200 feet.) <br /> TYPE OF SEPTIC ' ORK: NEW INSTALLATION l 1 REPAIRlAQDITIDN 1.1 DESTRUCTION l I IN septic system permitted if public sewer is <br /> Installation will serve: Residence — Commercial <br /> Other. <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments <br /> SEPTIC TANK n Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well Foundation p y <br /> j Total length/size <br /> 1 LEACHING LINE ❑ No. B Length of lines Foundation Property Line <br /> k <br /> • FILTER HED ❑ Distance to nearest: Well <br /> r# <br /> Size Number <br /> SEEPAGE PITS I i Depth Foundation Property_Line <br /> SUMPS Cl Distance,to nearest: Well <br /> k _. _ <br /> _ ,�•;'tr"'°"'.. <br /> —'�` `�QISPOSAL PONDS ❑ <br /> 1 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 /> I Home owner or licensed age s +gnature certifies the following: i certify that in the performance of the work for which this permit is issued, I signature <br /> shallnot <br /> employ any person in such am as to become subiect to workman's compensation laws of California." Contractor's +ring subjecrt tobworkman!sgCnmpensa <br /> t certifies the following: ,I ce ify to in the performance of the work for which this permit is issued, I shall employ persons <br /> tion laws of California." <br /> The applicant must call f r +r d i ons. Complete drawing on reverse-si <br /> o. <br /> Title: Date: <br /> Signed X <br /> F TMENT USE ONLY <br /> Date ` Area <br /> Application Accepted by Al <br /> Pit or Grout Inspection by Date�— <br /> Final Inspection by Date <br /> I Additional Comments: <br /> 4&6-6781 C� Lodi ;',369-3621 fl Manteca 823-7104 DTracy 835-6385 <br /> ❑ Stk <br /> f tealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> Applicant Reurn all copies to;Environmental H <br /> ` CK RECEIVED BY DATE PERMIT NO. <br /> FEE PUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> + EH 13-241REV.+/H5y <br /> EH 14-2a <br />