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3 <br /> APPLICATION..FOR PERMIT �5 <br /> SAN JOAO,UIN 'LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE.,.STOCKTON, CA <br /> Telephone (209) 466-6781 ,. <br /> PERMIT EXPIRESIYEAR FROM.DATEISSUED <br /> :.. <br /> (Complete in Triplicate) i "0 <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 Sanlioaquin <br /> Local Health District. <br /> iiLl 1 <br /> Job Address City Lot Size lao-;PM yI <br /> 5 <br /> Owner's Nametiu1 OeA h4*Address Phone <br /> i <br /> Contractor Address r License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 171 DESTRUCTION ❑ <br /> I <br /> PUMP INSTALLATION ED SYSTEM REPAIR 71OTHE <br /> DISTANLIE T.O NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD. POOP. LINE <br /> FOUNDATION+ AGRICULTURE WELL OTHER PITS/SUMPS <br /> INTENDED USE TYP FALL— PROBLEM AREA CONSTRUCTION IFICATIONS <br /> ❑ Industrial ❑ Open Bottom +"�-Aivnteca Dia. xcavation Dia- of Well Casing <br /> e of Casin Specifications i <br /> ❑ Domestic/Private ❑ Gravel Pack IJ Tracy 1(p 9 <br /> _ T e of Grout <br /> ❑ Public ❑ Other elta # Depth of'Grout,Seal yP <br /> ❑ Irrigation prox.,Depth ❑ Eastern Surface Seal Installed by <br /> Repair*1r1t r one ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 j <br /> Depth Filler Material (Below 501 <br /> iI <br /> K: NEW INSTALLATION ❑ REPAIR/ADDITION <br /> TYPE OF SEPTIC WOR ❑: DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> r � i <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:. Water table depth <br /> SEPTIC TANK t•�s. ❑ Type/Mfg- Capacity No. Compartments <br /> PKG. TREATMENT PLT. 71Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> Total length/size ' <br /> LEACHING LINE E1.7 No. & Length of lines <br /> s <br /> FILTER BED F1Distance to nearest: Well ' Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> ? <br /> SUMPS y L. Distance to riearest:- ....Well. Property Line� Foundation � i <br /> i DISPOSAL PONDS ❑ <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 /> y that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I certif <br /> I 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 co ansa <br /> I tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side.eL <br /> 87(. Signed X Title: Date: Z+Z <br /> FOR DEPARTMENT USE ONLY 03 <br /> Application Accepted by <br /> Date Area <br /> ?—, - <br /> I ' <br /> Pit or Grout Inspection by Date Final Inspection by_tLcr\ Date- <br /> Additional Comments: <br /> j ❑,Stk 466-6781 4 Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk:, CA 95201 i <br /> FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. Y <br /> INFO r} <br /> + EH 13-24(REV.- <br /> -t/R51 - !O`'' / <br /> EH 14-28 <br />