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0 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELLTON'AVE., STOCKTON, CA <br /> Telephone (2091 466-6781 I <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 /> r <br /> Job Address q1 2 i / City Lot Size rIQ� /` 3Qy PM <br /> Owner's Name ddress 7 Phone <br /> Contractor's Name ense No. _ Phone ' 0 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> • IN ED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ r k ❑ Tracy T Ing Specifications <br /> ❑ Public ❑ Other elta Depth of Grout Seal Type of Grout ' <br /> ❑ Irrigation _..�Approx. De Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type o p i' H.P. State Work Done <br /> Well destruction ❑ ell Diameter Sealing Material (top 50'1 <br /> Depth - Filler Material (Belo E <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADff14 DEQ RUCTIpg9 �Motic system permitted if public sewer is <br /> Grwithin 200 feet.) r <br /> Installation will serve: Residence_ Commercial Other <br /> a Z <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of DLIsppsal e <br /> Distance to nearest: Well v I/■ Foundation 2� Property Line�Ll , 0 ' F.. <br /> LEACHING LINE ❑ No. & Length of lines T tal length/size _ <br /> FILTER BED ❑ Distance to nearest: Well d oundation Property Line <br /> SEEPAGE PITS ❑ `Depth J Size umber <br /> SUMPS ❑ Distance to nearest: Well Foundation a Property Line <br /> DISPOSAL 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 /> 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 appI' t must call!Pall requir inspections. Complete drawing on reverse side. <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY ' <br /> Application Accepted by Date 2 Area ' <br /> Pit or Grout Inspection by Date 7 Final Inspection by Data <br /> Additional Comments: <br />` ❑ Stk 466-Ml ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 <br /> - int- Return all copies to: Environmental Health Permit/Services 1601 E. Hazehon Ave., P.O. Box 2009, Stk., CA 95201 <br /> y <br /> FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br />