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- APPLICATION FOR PERMIT Q <br /> t: <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (200) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> m (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 3697 City Lot Size 1549 X '790'5 PM <br /> Owner's Name Address W-1 ��"Q�L� Phone 83 S 9Z Z <br /> Contractor Address-%,q52-,S � License No. �9M/3 Phone <br /> TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC.TANK /00 SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation & Dia. of Well Casing fo <br /> �( <br /> Domestic/Private X Gravel Pack IC Tracy Type of Casing Specifications <br /> I <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal ,Type of Grout + <br /> LJ Irrigation �pprox. Depth El Eastern Surface Seal Installed by I <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter SealingY Material (top 501 <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic.system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms A <br /> Character of soil to a depth lof 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ J Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> 0i <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest:. Well Foundation Property Line 1 <br /> SEEPAGE PITS ❑ Depth Size Number r <br /> SUMPS El Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 0: <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 Sen 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." <br /> The applicant m st call for all-require inspections. Complete drawing on reverse side. <br /> I <br /> Signed X Date: <br /> R D PA M NT USE ONLYC <br /> Application Accepted by ' - Date �Q ¢��1" Area <br /> / Ay . <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: Ipl <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca .823-7104 ❑ Tracy 8354M% <br /> m Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CA RECEIVED BY t /DATE PERMIT'NO. <br /> + EH 13-24IREV.f/a5, <br /> EH 1426 1-7c.99 <br />