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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT f <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (249) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED ` <br /> (Complete in Triplicate) <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 City <br /> �t Lat Size ` PM <br /> Owner's Name Address Phone <br /> i <br /> --Contracinr —Address — �- ? - L -iVo Q _ Pho <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUC , <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES POSAl- FLO. Y'PROP. LINE <br /> _ FOUNDATION.. AGRICULTURE W OTHER WELL PITS/SUMPS Y <br /> I <br /> INTENDED USE TYPE OF WELL PROBLEM AR CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ M ca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private Cl Graver Pack j i. Tracy Type of Casing Specifications 1 <br /> f'I Public C i Other_ r i Delta Depth of Grout Seal, Type of Grout — <br /> I I Irrigation '�_Apprax. Depth l I Eastern Surface Sedl Installed by <br /> Repair Wo ❑ . Type of Pump H.P. State Work Done I <br /> Well Destruction ❑ Well Diameter•..., f Sealing Material (top 50') j <br /> Depth �. A� Filler Materia_66-low 501 <br /> TYPE OF SEPTIC WORK: INEW INSTALLATION i I REPAIR/ADDITION LI {DESTRUCTION eptic system permitted if public sewer is <br /> r available within 200 feet.) , <br /> Installation will serve: Residence----Commercial_ Other i <br /> Number of living units: •_Number of bedrooms <br /> f. #iti <br /> Character of-soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. El ! Method of Disposal <br /> J , <br /> Distante to nearest: Well Foundation i Property Line <br /> f <br /> LEACHING LINE; ❑ No. & Length of lines F _ _ _ Total lengthlsize <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I i Depth _ Size Number <br /> SUMPS r ❑ 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 /> i 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 /> certi he following: "I ce ify 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 alifornia." <br /> The applicant m tali for .req I d in ctio C let. drawing o reverse <br /> E' <br /> Sign. itle: .4 Date: <br /> Y <br /> FOR DEPARTNtENT USE ONLY <br /> Application Accepted by ' date Area <br /> t Pit or Grout inspection Data Final inspection by Date k <br /> I <br /> Additional Comments: `' } <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104'x,(,,L•7-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 />° FEEAMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT NO. <br /> 1Nf0 �f <br /> + EH 13-24/REV:1/8 si _ O�S'- �/ Vim <br /> I Z -��'�� / ~�� <br /> EH 14-26 - <br />