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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICTttiJ <br /> 1601 E. HAZELTON AVE., STOCKTON, CA v GFi Q`I <br /> Telephone (209) 466-6787 <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 descri ` <br /> r .made in compliance with.San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Reguf��g� n is <br /> Local Health District. Joaquin <br /> I' Job Address <br /> I City Lot Size PM <br /> Owner's Name Address tea_ <br /> •_ [� _ Phonefz�d g <br /> Contractor Addressr ¢1cense N <br /> TYPE OF WELL/PUMP: NEW o.WELL ❑ Phone !" <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR )4 OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES JW <br /> --�� DISPOSAL FLb. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> _ PITS/SUMPS <br /> INTENDED USE � <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Man- te�ca pia. of Well Excavation �1 <br /> 4(Domestic/Private ❑ Gravel Pack Dia. of Well Casing <br /> ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal <br /> ❑ Irrigation Type of Grout r/S <br /> =Approx. Depth O F�stem �-t Surface Seal Installed by 1 <br /> Repair Work n_e kl Type of Pump .�;. <br /> Well Destruction }I;P State Work-Done <br /> _ <br /> " """' t° <br /> ❑ Well Diameter Sealing Materia! (top 501) <br /> Depth Filler Material f8elow 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ I septic system permitted if public sewer is 3 <br /> Installation will serve: Residence_' available within 200 feet.} <br /> Commercial_ Other -` .,, �"`�� h* <br /> Number of living units: j- <br /> Number of bedrooms ;I l <br /> Character of soil to a depth of 3 feet: ( # <br /> r SEPTIC TANK Water table depth <br /> ❑ Type/Mfg <br /> PKG. Capacity No. Compartments <br /> TREATMENT PLT. ❑ I - <br /> i _ <br /> Distance to nearest: Method of Disposal <br /> Well ! - <br /> Foundation Property Llrie <br /> LEACHING LINE ❑ No. &Length of lines ., <br /> FILTER BED Total length/size <br /> ❑ Distance--to-nearest: Well Foundation <br /> } Property Lie <br /> SEEPAGE PITS ❑ Depth Size a t <br /> SUMPS Number = <br /> ❑ Distance'to nearest: WellFoundation - Property Line - + <br /> DISPOSAL PONDS ❑ o. <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. I <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 com <br /> certifies the following: pensatian laws of California."Contractor's hiring or sub-contracting signature � <br /> g:"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 m t call for al fired inspections. Complete drawing on side. <br /> Signed Title: <br /> Date: <br /> I OR DEPARTMENT USE ONLY <br /> Application Accepted by ilk. g <br /> Date Area U <br /> Pit or Grout inspection by <br /> Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 955201 <br /> a <br /> FEE UE AMOUNT REMITTED <br /> INFO MOUNT DCASH RECEIVED BY DATE PERMIT''N0. <br /> + EH 13-241REV't/a51 �S p <br /> EH 1 -28 <br />