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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> t (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 /> 70 7_ e d City Lot Size �� — PM <br /> Job Address <br /> Address 0 Phone <br /> Owner's Name: .( i <br /> Contractor <br /> Address 3 OC���� ansa No. Phone+ �� � <br /> TYPE OF.WELLIPUMP: y,. . NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 1 <br /> DISTANCE TO NEAREST:' SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial , ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> r Type of Casing Specifications <br /> El Domestic/Private El Gravel Pack ❑ Tracy YP <br /> Depth of Grout Seal Type of Grout <br /> A ("I Public f ❑ Other .I �, Cl Delta De p <br /> f I I Irrigation _.-Approxi Depth 1 1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done — <br /> �i i <br /> Well Destruction' ❑ Well Diameter Sealing Material (top 501 <br /> f . <br /> DepthFiller Material (Below 50') <br /> j TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION i I DESTRUCTION i I (No septic system permitted it public sewer'is <br /> h.1 available within 200 feet.I <br /> Installation will serve: Residence i� Commercial Other G <br /> Number of living units: __L_ Number of bedrooms4 <br /> I <br /> _ Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK L�TypelMfg Capacity ff <br /> No. CompartmentsPKG. TREATMENT PLT. D Method of D7is�posal <br /> i <br /> Distance to nearest. Well Foundation,2W Property Lines /I <br /> ` 4t <br /> t <br /> LEACHING LINE Ca✓No. & Length of lines.. 4 r Total length/size <br /> FILTER BED; ❑ Distance-to-nearest: -"Well b ". Foundation Property Line <br /> lr <br /> i R O E <br /> SEEPAGE PITS ItY Depth; '.t. r Size Number q <br /> F SUMPS L1 Distance to nearest: Well Foundation �St Property <br /> DISPOSAL PONDS ❑ <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 Distr!ct. <br /> Home owner or licensed agent's signature certifies the following: "I certify that!n 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 /> n _ hich this permit is issued, i shall employ persons subject to workman's compensa- <br /> certifies the following: "I certify that itheperformance of the work for w <br /> tion laws of California." <br /> The applicant must call for a! required inspections. Complete drawing o verse side: r $ <br /> Signed X 1 <br /> Title: �`� Date: /-0 "P/? <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by �_ _ - _ Date <br /> 1 �✓ v Area f <br /> Date al Inspection y Date 2 � <br /> A Pit r Grout Inspection by t <br /> rr 'r <br /> Additional Comments: � y <br /> ❑ Tracy 835-6385 <br /> ElStk 466-6781 O Lodi 369-3621. ❑ Manteca 823-7104 , <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE , C RECEIVED BY DATE PERMIT NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED r CASH <br /> 124 <br /> a EH 13-24 iREV.1/H 51 1 <br /> EH 14.26 <br />