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4 - <br /> . APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE.TON AVE., STOCKTON, CA 1 <br /> Telephone (209) 466-6781 I <br /> 4•—" PERMIT EXPIRES 1.YEAR 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 Sari 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. .., r- <br /> Job Address 4' � ii Ity Lot Size PM <br /> Owner's Name Address Phone <br /> i <br /> Contractor ess nse No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTR CTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ QT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSA PROP. LINE <br /> FOUNDATION AGRICULTURE WELL R WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CO CTION SPECIFICATIONS <br /> ❑ Industrial' r. ❑ Open Bottom ❑ Manteca ia. of Well Excavation . Dia. of Well Casing j <br /> ❑ Domestic/Private El Gravel Pack ❑ T Type of Casing r a Specifications' i L�- <br /> f <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout !r <br /> ❑ Irrigation ox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ype of Pump H.P. State Work Done ' l <br /> Well Destr n ❑ Well Diameter Sealing Material.{top 50') f ] <br /> Depth Filler Material (below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION L1 DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_Z Commercial_ Other <br /> Number of living units: Number of b rooms r ' <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg r Capacity-4000No. Compartments <br /> PKG. TREATMENT PLT. ❑ # /J e Method of is sal / <br /> Distance to nearest: Well o tion "' * Property Line rf <br /> LEACHING LINE No. & Length of lines ' d` Total"length/size 5j <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line t <br /> SEEPAGE PITS ❑ Depth ti ( ; Size Number t G <br /> SUMPS ❑ 'Distance to nearest: Well Foundation '° Property Line � f <br /> DISPOSAL PONDS ❑ + ty <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. f , <br /> Home owner or licensed agent's signature certifies the following: "I certify—tthat in the performande 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." <br /> The applicant si q r eq Ire in pections. Co I drawing on ve side. I <br /> Signed Title: _ # Date: <br /> W FOR DEPARTMENT USE ONLY i <br /> Application Accepted y Dat®',a-�a"'¢_g�^ Are f <br /> Pit or Grout Inspection by 1 ?ate Final lnspection'by Date Z <br /> yi <br /> Of <br /> Additional Comments: ! <br /> ❑ Stk 466.6781 _ ❑ Lodi—.369-3621r -❑ Manteca `823-7104. ❑ Tracy 835.6385 <br /> _:..• Applicarit='Return all copies_ to: Environmental Health Permit/Services 16D1 E. Hazelton.Ave., P,O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED " CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> + EH 13-24(REV.1/a 5) q �`1 <br /> EH 14-28 / r <br /> 14 <br />