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' APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> { Telephone (209) 466 6781 <br /> x. .. <br /> k «PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' <br /> (Complete in Triplicate) <br /> I � • <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 's City Lot Size PM ' <br /> Owner's Name Address ,. Phonal <br /> 4 Contract Address �e� -���1 <br /> y Licensd`iV6 Pho <br /> TYPE OF.WELL/PUMP: NEW WELL ❑ _ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ISPOSAL FLO. PROP. LINE <br />' FOUNDATION AGRICULTU L OTHER WELL PITS/SUMPS _ <br /> j <br /> INTENDED USE TYPE OF UVELL �PR08 EA CONSTRUCTION SPECIFICATIONS <br /> f€ L1 Industrial ❑ Open Bottom Manteca # Dia. of Well Excavation I Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Grave ❑ Tracy r,&Type.of Casing Specifications" <br /> F] Public ther Ci Delta Depth of.Grout Seal ? Type 6f Grout <br /> I i Irrigation "�_Approx. Depth I I Eastern Surface Seal Installed by r <br /> Repair Done L7 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material (top 50'1 <br /> Depth Filler Material (Below 50'1 <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION f1' DESTRUCTION ( I (No septic system permitted if public sewer is <br />! �' _ a_vaiiable within 200.feet.) <br /> Installation will serve: Residence�"..°Cominer`:cial Other a <br /> Number of living units: _L_ Number of bedrooms. <br /> Character of soil to a depth of 3 feet Water:table depth <br /> SEPTIC TANK ❑' Type/Mfg A--: '� rapacity }� om No. Compartments <br /> PKG. TREATMENT PGT. ❑ P nts <br /> " Method of Disposal i <br /> Distance to nearest: Well Foundation Property.Line <br /> LEACHING LINE ` 3 _�f No. & Length of lines <br /> Total length/size i <br /> -'*FILTER BED ❑ Distance to nearest Well ► Foundations' r � <br /> {�( Property Line `_" i <br /> SEEPAGE PITS Depth Size.? .3 Number' l I <br /> SUMPS CI Distance to nearest: Well '` f1 � ' <br /> U Foundation &! Property Line 2 k <br /> DISPOSAL PONDS ❑ Aj�i s=`• <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 k <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 taws 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 ust call for aft req 'red inspections. Complete drawing o arse si e. f <br /> Signed tJ Jr <br /> - Title: Date: <br /> FOR DEPARTMENT USE ONLY I l i <br /> r ` k <br /> Application Accepted by bate � � A ea C9 <br /> Pit or Grout Inspection Date Final Inspection by Date `'°?7-Ap <br /> I <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 2009, Stk., CA 95201 (� <br /> . FEE _ <br /> AMOUNT DUE AMOUNT REMITTED CK ,, RECEIVED BY DATE PEERMIT•NO. <br /> INFO CASH <br /> r.EH 13-24 MEV.l/H 5) <br /> EH 14-28 <br /> - O Y <br />