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`4 APPLICATION FOR PERMIT '''"yr <br /> SAN JOAQUIN�LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE._STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> I PERMIT EXPIRES 1 .YEAR FROM DATE.ISSUED ti N ED) <br /> t;.; (Complete in Triplicate) 3 <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 AddressCity Lot Size {' PM <br /> I Owner's ame Address <br /> Phone <br /> 5 <br /> Contracto Address License No. Phone <br /> TYPE OF WELL/ UMP: NEIN WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ i - SYSTEM REPAIR ❑ _# OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK ! SEWER LINES DISPOSALFLD, 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 r Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing '"'° Specifications <br /> ❑ Public ❑ Other y.❑:Delta Depth of Grout SealT" <br /> '- ype of Grout <br /> ❑ Irrigation __4pprox. Depth C7 Eastern Surface Seal Installed,by .°ate tl <br /> Repair Work Done ❑ Type of Pump f N.P. State Work Done <br /> Well Destruction ❑ 'Well Diameter ' t Sealing Material Itop 501 <br /> Depth Filler Material (Below 50'} 3 t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> X available within 200 feet.) <br /> Installation will serve: Residence— Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of,3 feet: ! 1 1 - _ , 1 Water table depth <br /> SEPTIC TANK ElType/Mfg �'C pacityNo. Compartments <br /> PKG. TREATMENT PLT. ❑ # _ ,_ } Method of Disposal <br /> Distance to nearest:a Well Foundation ` Property Line <br /> s # Vii✓, � <br />` LEACHING LINE ❑ No. & Length of linesR Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation # Property Line <br /> 3 ( } <br /> SEEPAGE PITS ', ❑ Depth Size 4 ' Number I <br /> SUMPS z -4' - ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS "` ❑ t s <br /> I hereby certify that'( 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 /> t <br /> Home owner or licensed agent's signature certifies the following: "I certify.that in the.perlormance 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.". ! F <br /> 1 ! <br /> The applicant Wust call for' I re uir spections. Compl drawing o averse side. <br /> .1 71 <br /> Signed Title: ` <br /> Date: <br /> I FOR DEPARTMENT USE ONLY ffi, <br /> Application Accepted by I Date_. 6,-1 � I Area <br /> d <br /> S <br /> .Pit or Grout inspection by i Date l Finaklnspection by Date <br /> i <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369:3621 C1 Manteca 823-7104 ❑ Tracy 8355-6385 <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 CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH13-24(REV,t/55) <br /> EH 14.29 <br />