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APPLICATION;FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES i 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 /> i <br /> Joh Address Z44 � <br /> City Lot Size PM <br /> Owner's Name -r Address phone 7—cam 6 l <br /> Contract [ !% Address1 <br /> License No.4��[92 Phone <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 /> IN1 ENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` <br /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Ll Domestic/Private ElGravel Pack ❑ Tracy Type of Casing^` Specifications <br /> ❑ Public ❑ Other E] Delta Depth of,Grout Seal Type of Grout <br /> ❑ Irrigation --Approx.Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump>. H.P. } State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 50') F <br /> Depth' """ "" Filler'Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION eptic system permitted if public sewer is <br /> Installation will serve: Residence, Commercial available within 200 feet.) <br /> _ Other <br /> Number of living units: Number of bedrooms j <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 Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length f.lines Total length/size 1 <br /> FILTER BED ❑ 'Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size I Number <br /> SUMPS ❑ Distance to nearest: Well Foundation t Property Line <br /> DISPOSAL PONDS ❑ E. <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 J <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, 1 shall not - <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature i <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 ust call for all r inspections. Complete drawing on rave ide.- <br /> Sign Title: : <br /> s Date <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 13 _E-7 Area 0� <br /> Pit or Grout Inspection by 44Date Final Inspection by Date l 12 �e5�) <br /> Additional Comments: � 4 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 11 <br /> FEE 144AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT NO. <br /> E <br /> INFO <br /> + EH 1 -241REV.tia51 �i <br /> EM -28 <br />