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la APPLICATION FOR PERMIT <br />=` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 1 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> Ir (Complete in Triplicate) <br /> I application is <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 app' <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1662 for w ii/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District, II <br /> S City p at Size PM <br /> Job Address / <br /> k Address Phone <br /> Owner's !Name <br /> Contractor <br /> Address License Nv. Phone <br /> TYPE OF WELLlPU NEW WELL ❑ 'WELL REPLACEMENT 71 DESTRUCTION LJ <br /> P44P INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Cl <br /> DISTANCE.TO NEAREST:.SEPTIC TANK SEWER LINES <br /> DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing Specifications' <br /> ❑ Domestic/Private ❑ Gravel Pack © Tracy YP g Type of Grout-- <br /> ('I <br /> 4 , <br /> Public ❑ Other CI Delta Depth of Grout Seal YPIV <br /> I I Irrigation �I _Approxi Depth —I I Eastern Surface Seal Installed by - <br /> Repair Work Done El Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth -- Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION Li DESTRUCTION availab <br /> o septic system <br /> m rmiitted if public sewer is <br /> 0 feet.I <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: II Number of bedrooms <br /> Character of soil to a depth of 3 feet: 1 Water table depth 1 <br /> r• <br /> SEPTIC TANK. FlType/Mfg _ Capacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> i <br /> 14'Distance to nearest: Well Foundation Property tine <br /> LEACHING LINE ❑11i No. & Length of lines Total length/size <br /> " FILTER BED• ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS LI''l Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑I <br /> f 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." 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." It <br /> The applican tst call for all required inspections. Com lete drawing on arse side. a <br /> Title: Date: <br /> Signed <br /> r FOR DEPARTMENT USE ONLY t <br /> Application Accepted by <br /> Date -- Area ` <br /> Final Inspection b l- 'o''?� �^ ''t — Date /0 � <br /> Pit or Grout Inspection by Date y <br /> Additional Comments: `7` (J� <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 /> I� <br /> F E AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> yr y� /0 +( <br /> J <br /> .. +.EH13-241REV.iiMSy ! �' ✓�`vV � ."L /tef1 <br /> EH 1448 l/ <br />