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Y <br />s <br />APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRI <br />1601 E. HAZELTON AVE., STOCKTON, C <br />Telephone (209) 466-6781 <br />PERMIT EXPIRES 1 YEAR FROM DATE IS! <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. <br />Job Address a WAt, City b Lot Size _1 2_x.1 Acres PM <br />Owner's Name 1 Address a Phone T1A- L3 <br />Contractor's Name <br />TYPE OF WELL/PUMP: NEW WELL ❑ <br />PUMP INSTALLATION ❑ <br />DISTANCE TO NEAREST: SEPTIC TANK <br />FOUNDATION <br />INTENDED USE <br />❑ Industrial <br />❑ Domestic/ Private <br />❑ Public <br />❑ Irrigation <br />Repair Work Done ❑ <br />Well Destruction ❑ <br />OF SEPTIC <br />License No. <br />Phone <br />WELL REPLACEMENT ❑ DESTRUCTION <br />SYSTEM REPAIR ❑ OTHER ❑ <br />SEWER LINES DISPOSAL FLD. PROP. LINE <br />AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br />TYPE OF WELL <br />PROBLEM AREA <br />CONSTRUCTION SPECIFICATIONS <br />❑ Open Bottom <br />❑ Manteca <br />Dia. of Well Excavation <br />❑ Gravel Pack <br />❑ Tracy <br />Type of Casing <br />❑ Other <br />❑ Delta <br />Depth of Grout Seal <br />--Approx. Depth <br />❑ Eastern <br />Surface Seal Installed by <br />Type of Pump <br />H. P. <br />State Work Done <br />Well Diameter Sealing Material {top 50'1 _ <br />Depth Filler Material'(Below 501 _ <br />NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRU <br />Installation will serve: Residence , Commercial <br />Number of living units: Number of bedrooms <br />Character of soil to a depth of 3 feet: <br />SEPTIC TANK ❑ Type/Mfg <br />PKG. TREATMENT PLT. ❑ <br />Distance to nearest: Well <br />Other <br />Dia. of Well Casing <br />Specifications <br />Type of Grout_ <br />(No septic system permitted if public sewer is <br />available within 200 feet.) <br />Water table depth <br />Capacity No. Compartments <br />Method of Disposal <br />Foundation Property Line <br />LEACHING LINE ❑ No. & Length of lines <br />FILTER BED ❑ Distance to nearest: Well Foundation <br />Total length/size_ <br />Property Line <br />SEEPAGE PITS ❑ 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 per such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub -contracting signature <br />certifies the fol ing: certifyth t 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 lifornia." <br />The applican must call r all wired inspections. Complete drawing on reverse side. <br />Signed Title:.(J{f Date: --v 4 . 7 �" d <br />FOR DEPARTMENT USE ONLY <br />Application Accepted by Date OL r Area _ l � 0 <br />Pit or Grout Inspection by Date Final Inspection by Data � —2-2- <br />Additional <br />2ZAdditional Comments: <br />❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-8385 <br />Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br />FEE INFO AMOUNT DUE AMOUNT REMITTED C K H RECEIVED BY DATE PERMIT N0. <br />+ EH 13-24 /REV. 1eJ83l <br />EH 1120 <br />.ia E i,- <br />a <br />