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APPLICATION FOR PERMIT <br /> j SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> yam; <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> rib . THs appcation is <br /> Applicaion is hereby all the work herein <br /> made int <br /> compliance withde tSanoJoaqu nthe n Joaquin County ordinanHealth ce No.District49 for sewage or permit <br /> No 1862 for well/pump and the Rules and Regula <br /> tions of the San Joaquin <br /> Local Health District. <br /> l ; <br /> d <br /> Job Address City Lot Size M <br /> '- <br /> Owner's Name <br /> Address Phone <br /> Phone <br /> Contractor's Name <br /> icense NO. <br /> TYPE OF WELLIPUM NEIN WELL ❑ ' WELL REPLACEMENT ❑ DESTRUCTION Ll <br /> PUMP INSTALLATION ED SYSTEM REPAIR ❑ OTHER El <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �w <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing <br /> Specifications <br /> C1 Domestic/Private E3 Gravel Pack- El Tracy Type of Casing <br /> El Public El Other ❑ Delta Depth of Grout Seal Type of Grout <br /> []'irrigation __--Approx. Depth ❑ Eastern Surface Seal Installed by - <br /> Repair Work Done EJ Type State Work Done Type of Pump t, <br /> Well Destruction, ❑ Well Diameter Sealing Material {top 501 {� <br /> k Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION V REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is V <br /> r available within 200 feet.) <br /> Installation will serve: Residencemmercial— Other <br /> r of linin its: Number of bedrooms ��. <br /> a jVUyribe g un <br /> Water table depth <br /> Chara•rter of soil to a depth of 3 feet: ''..��}} ` <br /> SEPTIC TANK ❑ Type/Mfg CapacitylL� No. Compartmentsto <br /> PKG. TREATF.yENT PLT. ❑ + Method of Disposal C 1 <br /> Distance to nearest: Well Foundation — Property Line/o�— a <br /> crh <br /> LEACHING LINE " No. & Length of lines Total lengthlsize _ <br /> �- <br /> FILTER BED I ❑ Distance to nearest: Well;D p Foundation fin Property Line <br /> II A i <br /> SEEPAGE PITS Depth __-._-Size Number <br /> q .' Foundation Property Line <br /> SUMPS ❑ Distance to nearest: -��:=- j <br /> f.. <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: "l 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 /> rr 1_ <br /> I The applicant st for ll requ" inspections. Co plate drawing on re rs side. <br /> ' Date: <br /> Signed G Title;; <br /> w 4 w FOR DEPARTMENT USE ONLY <br /> Date 8 <br /> Application Accepted by cd1 r <br /> Pit or Grout Inspection by -� Date Final Inspection by Date C i <br /> Additional Comments: r <br /> ❑ Stk 466.6761 0 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354385 , <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> R <br /> FEE CK RECEIVED BY DATE PERMIT'NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> + EH 1324(REV.10!63) <br /> EH 14-26 <br />