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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 /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) z.�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 -ot Size PM it <br /> Owner's Name - Address '�al b Phone <br /> Contractor t^ Address �O 0, License_No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ ,DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ~OTHER ❑ A } <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1� <br /> FOUNDATION -- AGRICULTURE WELL OTHER WELL f ITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />- ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I"1 Public ❑ Other I L1 Delta Depth of Grout Seal Type of Grout <br /> I t Irrigation _.-Approx. Depth I I 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 w <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION 111No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial T Other " <br /> Number of living units: Number o ams y <br /> Character of soil to a depth of 3 feet: �.Ie, e depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity 10< No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundati Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total th/size <br /> FILTER BED ❑ Distance to nearest: Foundation Prop Line <br /> SEEPAGE PITS i 1 Depth."­'­ <br /> ept size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> 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 /> 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, t shall employ persons subject to workman's compensa- <br /> tion laws of California." I <br /> Thea applicant must call for all a <br /> pp ❑uirad inspections. Complete drawing on reverse side. r <br /> Signed X LA Aj Title: __ � �n�� �� Date: v t <br /> FOR DEPARTMENT USE ONLY �f <br /> Application Accepted by rOt Date C '1 4 7 Area I <br /> Pit or Grout Inspection by ate Final Inspection by Date <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 2008, Stk., CA 95201 y' <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED erD <br /> ^S7CA}SHH RECEIVED BY DATE PERMIT NO. <br /> + EH 13-24(REV.i/nsY '�. "}-�1- U bU l �1 l �,e'"� J � 2 ��� <br /> EH N-26 LJ�`✓ Q 6 <br />