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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 7'YEAR FROM DATE ISSUED <br /> j (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.- 1 <br /> a <br /> Jab Address 0 ' City Lot Size PM <br /> >� <br /> Owner's Nam Address �5fq� Phone <br /> Contractor Address 7t �"� License No.329 zz Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ YRUC-TION-O <br /> r <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE O�WELL PROBLEM ARE CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Botto ❑ Monte Y rDia. of Well Excavation Dia_of Well Casing <br /> ❑ Domestic/Private ❑ Gravel`Pack- ' ❑" cy Type of Casing Specifications <br /> 1 71 Public Cl Other } C-1:.Delta .--�,�-Depth of Grout Seal Type of Grout---_ <br /> I I Irrigation ..Approx epth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type ump —H..P. State Work Done _ <br /> Well Destruction ❑ ell Diameter # ^Sea ling.Material Itop 501 <br /> Depth Filler Material i6elow 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I'] REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is <br /> r. <br /> t+ a available within 2DO feet.) <br /> i _ <br /> Installation will serve: ..Residence! Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of3 feet:_ Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> r PKG. TREATMENT PLT. ❑ I Method of Disposal" <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINErr No. & Length of lines Total length/size <br /> r FILTER BED ❑ Distance to nearest: WellrQl Foundationf b 1 Property Line h <br /> SEEPAGE PITS Depth r ` 44 SizeNumber <br /> SUMPS 0 Distance to nearest: „Well, MOL. 'Foundation 1Q ki Property Line <br /> DISPOSAL PONOS © <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and 0 <br /> rules and regulations of the Sari•Joaquin Local Health District. "-..` <br /> Home owner or licensed agenWs signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> fff 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 /> f The applicant mus all for all e:�l 'inspections. Complete drawing on reverse side. <br /> I <br /> Signed X Title: Date: <br /> FOR DEPARTM NT USE ONLY <br /> Application Accepted by Date 2— Area <br /> Pit or Grout Inspection by Date Final Inspection Date <br /> r - <br /> Additional Comments: <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 2W9, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK 4 RECEIVED BY DATE PERMIT-NO. <br /> INFO CASH <br /> + EH 1324 1REV.1/R 51 <br /> EH 14.24 © �" S <br />