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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 1YEAR 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. y�-�/ <br /> City�G Oa-t Size PM <br /> Job Address <br /> �^ l�/ Address Phone <br /> Owner's Name I J � _ <br /> Address License No..5�tg Phone_ <br /> Contractor r <br /> TYPE OF WELL/PUMP: NEW WELL Q „WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR LJ OTHER ❑ <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 <br /> Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _ <br /> pe of Casing Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Grout <br /> FI Public Cl Other FI Delta Depth of Grout Seal S <br /> I i Irrigation --Approx. Depth 1.1 Eastern Surface Seal Installed by Ul! <br /> H.P. State Work Done , ^ <br /> Repair Work Done ❑ Type of Pump <br /> Well Destruction kms❑, Well Diameter __Sealing_S.ealing Material (top 501 _ <br /> Depth Filler Material (Below 55) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIRIADDITION ESTRUCTION I I availableseptic <br /> wi within 200 feet.) if public sewer is <br /> Installation will serve: Residence_— Commercial Other <br /> it <br /> Number of living units: Number of bedrooms I ' <br /> Water table depth <br /> Character of sail to a depth of 3'feet: G No. Compartments - <br /> , <br /> SEPTIC TANK ❑ Type/Mfg4/ �' Capacity <br /> r Method of Disposal <br /> PKG. TREATMENT PLT. 0 <br /> Distance to nearest: Well s50="Foundation /0 Property Line <br /> ► x <br /> I LEACHING LINE U. No. & Length of lines a Total lengthlsize <br /> FILTER BED ❑ Distance to nearest: Well <br /> Foundation Property Line <br /> SEEPAGE PITS } C I Depth Size <br /> Well <br /> 1^��;=_— Number <br /> i�"" "Foundation Property Line ; <br /> SUMPS Ll Distance to nearest: r _ <br /> DISPOSAL PONDS- C7 _ �� <br /> I hereby certify that I have prepared this application and.thai the work witl 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 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 /> i of California." Contractor's hiring or subcontracting signature <br /> employ any person in such manner as to become subject to workman's compensation laws <br /> o <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 /> I The applicant 'ust all for all equiredoinspections. Complete drawing on reverse side. <br /> Signed X <br /> Title: Date: <br /> 1 .FOR DEPARTMENT USE ONLY Q <br /> Date Area <br /> Application Accepted by i <br /> Date . Final Inspection by li Date <br /> Pit or rout Inspection b / I i <br /> j Additional Comments: <br /> 13Stk 466-6781 E) Lodi 369-3621 ❑ Manteca 623-7104 El Tracy 835 6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> C <br /> FEE CK RECEIVED BY DATE PERMIT'NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> s EH 13-24 IREV.S/h 510-0 <br /> 1aa 18--? 1 `%1,) <br /> EH 14-28 <br />