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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 t <br /> (Complete in Triplicate) <br /> Application is heteby 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 I <br /> Local Health District. <br /> Job Address ✓ 5�L. City 59AI Lot Size PM ` <br /> Owner's Nam03 i Address -3d /Y 'J l - Phone <br /> I <br /> Contractor Address License No. 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 /> INTENDED USE , TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS p <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I <br /> P Public n Other Cl Delta Depth of Grout Seal Type of Grout . <br /> I I Irrigation ­Approx. Depth l I Eastern Surface Seal Installed by y <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTIoNX fNo Septic system permitted if public sewer is <br /> ailable within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms I <br /> Character of sail to a depth of 3 feet: - Water table depth <br /> SEPTIC TANK ❑ Type/Mfg r Capacity No. Compartments ` <br /> PKG. TREATMENT PLT. ❑ -� Method of Disposal - R <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines --Total lengthisize I <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line } ' <br /> SEEPAGE PITS l I Depth _Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <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 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 Contractors 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 appficantwpst ca for all requiredspectiq tr mplate drawing on reverse side. (3' <br /> Signed X X, Q'Tif/J Title: Date: p a <br /> USE ONLY <br /> Application Accepted byL a�=- <br /> Date _ 5 Area 0 <br /> Pit or Grout Inspection by ry Date Final Inspection byDate, i <br /> ,�P� <br /> Additional Comments: <br /> i <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 <br /> r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY <br /> INFO CASH DATE PERMIT NO. <br /> a EH 1 -2411tEV.i/k51 O C.1 . b(] ���� �^ <br /> EH 144-2e loll�` <br />