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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEATH DISTRICT <br /> 1601 E. FIAZELTON AVE., STaCKTON, CA <br /> Telephone (20§1466-6781 <br /> PERMIT EXPIRES 1 YE R FROM DATE ISSUED <br /> (Complete i 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address - <br /> } City�--t—t�oc .r1Lot Size PM <br /> Owner's Name I C _ j Address - S� I <br /> fn111 /� <br /> ko pu�1-' Phone <br /> Contractor - �/ <br /> TYPE OF WELL/PUMP: /Address Lic ense Nt Phone 914 <br /> NEW WELL LJWELL REPLACEMENT ❑ DES I KOL,I ION <br /> LI- <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ X�,. <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 Q <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca <br /> Dia. of Well Excavation Dia. of Well Casing <br /> C1 Domestic/Private EJ Gravel Pack CJTracy Type of Casing Specifications <br /> ( I Other f-1 Delta Depth of Grout Seal <br /> i I Irrigation ­Approx. Depth [ I EasternType of Grout <br /> H.Repair Work Done ❑ Type of Pump Surface Seal Installed by <br /> _ <br /> Well Destruction �1� State Work Done <br /> Well Diameter Sealing Material Itop 501 <br /> Depth Filter Material (Below 50) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION i I (No septic system permitted if public sewer is <br /> Installation will serve: ResidenceCommercial_ Other available within 200 feet.) <br /> Number of living units: Number of bedrooms r. <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANKWater table depth <br /> ❑ Type/Mfg <br /> PKG. TREATMENT PLT, LJCapacity No. Compartments <br /> Distance to nearest: WellMethod of Disposal <br /> Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of fines <br /> FILTER BED Total length/size <br /> ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS I i Depth Size <br /> � Number <br /> SUMPS Ll <br /> Distance to nearest: Well Foundation <br /> DISPOSAL PONDS E) 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 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,1 shall employ persons subject to workman's compensa- <br /> tion taws of Calif- 7.. —. <br /> The applicant st call for all requ' inspectio Complete drawl on rev rse side. <br /> Signed <br /> rile: � <br /> Date: <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by � `t�r�� <br /> Date Area <br /> Pit or Grout Inspection by bate. <br /> Final Inspection byDate _ <br /> Additional Comments: <br /> El Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 635-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 <br /> FEE AMOU <br /> INFO NT DUE I AMOUNT REMITTED CASH RECEIVED BY DATE <br /> PERMIT N0. <br /> EH 13-24+ EH 14-25 IHEV,r i n 5t -- <br />