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APPLICATION FOR PERMIT <br /> 4 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />` 1601 E. HAZELTON AVE., STOCKTON, CA / <br /> Telephone (209) 466-6781 <br /> rl PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> i 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. /�} /�/J { I <br /> Job Address `t.4J ! (/ 1 �,/II tl_Z_ - City- 572�i_.__ Lot Size JrOX j042 PM <br /> Owner's Name ress mas­ / ff lnk L" 4= Pal — Phone <br /> Contractor - {_(DEQ-- Address License No. Phone <br /> TYPE_ OF WELL)-PUMP:-,,— .,eNEW,WELL ❑ WELL REPLACEMENT ❑ y DESTRUCTION �. <br /> JJ PUMP INSTALLATION ❑ wWSYSTEM REPAIR ❑ J OTHE <br /> DISTANCE& NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL; OTHER WELL - . i PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS' } �- <br /> ❑ Industrial / ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private - ❑ GrdVel'Pack—❑Tracy­_ .--Type of Easing----- - Specifications <br /> M Public n Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation Approx. Depth l 1 Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H,P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material /top 50'1 <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l l REPAIR lADDITION-I 1 DESTRUCTION (No septic system permitted if public sewer is <br /> f <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number,of bedrooms 1 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ r Type/Mfg l acity } - No. Compartments <br /> PKG. TREATMENT PLT. ❑ r Method of Disposal <br /> 1 Distance to nearest: Foundation 'Property Line <br /> t <br /> LEACHING LINE ❑ N�Anceto <br /> ines Total length/size <br /> FILTER BED ❑. st: Well Foundation I Property Line <br /> SEEPAGE PIT ­I 1. Depth Size Number <br /> SUMP {• ,L) 1 Distance to rieaiie,= Weil Foundation Property Line <br /> OSAL PONDS ❑ t '�'`^ ' <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 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 Californi y <br /> The licant must all r a re u ed spections. Complete drawing on reverse side. <br /> �r <br /> Signed X Title: Date: � <br /> f <br /> FOR DEPARTMENT USE ONLY 1 1 <br /> Appl' ion Accepted by Date Area <br /> � v <br /> Pit or Grout Inspecti y { Date Final Inspection by LDate <br /> Additional Comments: ' <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 O Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> i <br /> FEE <br /> INFO C'AMOUNT DUE AMOUNT REMITTED O'K �� RECEIVED,BY 'DATE ^P-�ERMIT'NO. <br /> + EH 1 -241REV.1i85} o �a �� 1 } - TJ <br /> EH 144.2a <br />