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t <br /> APPLICATION FOR PERMIT _ <br />( SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 r <br /> 5 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 k .2a I ✓ City PM <br /> Owner's Nam /� ', ss r �O A�/ ��i/? z Phoneq6q q <br /> 719 <br /> j — <br /> Contract- W- License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> t, DISTANC EA REST: SEPTIC TANK - SEWER-GINES"''"^'- DISPOSAL FLD. ROP."LINE <br /> NDATION AGRICULTURE WELL OT Eli-WEC1_ PITS/ SUMPS <br /> INTENDED USE TYPE OF WE OBLEM AREA" CON l7ICT ON. SPECIFICATIONS <br /> t ❑ Industrial ❑ Open Bottom ❑ Mantec Dia. of Well Excavation Dia. of Well Casing <br /> 1Q <br /> ` # W <br /> ❑ Domestic/Private ❑ Gravel Pack cy--�-s----w-�-Type- � � � Specifications <br /> f'1 Public Cl Other Cl Delta Depth Grout Sea Type of Grout <br /> I I Irrigation �P.f <br /> x. Depth I I Eastern Surfacal Installed byRepair Work Done mp H.P. "is State Work Done <br /> j Weil Destruct ❑ Well Diameter Sealing Material (top 50') n� <br /> Depth ? w Fillet Material IBelow:50'I.' i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I:1 REPAIR/ADDITION I I" DESTRUCTION Mo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial'_ Other <br /> I Number of living units: l Number.of bedrooms <br /> Character of soil to a epth of 3 feet: I " Water table depth <br /> " SEPTIC TANK' " Type/Mfg {Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ s / Method of Disposal <br /> Distance to nearest: t 'Well Foundation PropertV?Line <br /> LEACHING LINE ❑ No. & Length of lines-F Total length7size <br /> FILTER BED ❑ Distance to nearest: ' Well Foundation Property Line <br /> SEEPAGE PITS i I Depth i Size Number <br /> SUMPS Ll Distance to nearest: r Well Foundation - Property'Line <br /> DISPOSAL PONDS C] : 't "._. _ -' "- . <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 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,1 shall employ,persons subject to workman's compensa- <br /> tion laws of California." ---iu . <br />(I The applicant must call for all required inspections. Complete drawing on reverse side. - r - <br /> Signed L,Gt; Title: Date4, <br /> a y FOR DEPARTMENT USE ONLY <br /> Application Accepted b4c Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Dat <br /> y <br /> Additional Comment_s: <br /> ❑ Stk 466.6781 ❑ Lodi 369-36211 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant • Return all copies'to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE1 INFO AMOUNT DUE AMOUNT REMITTED C K H RECEIVED BY DATE P^ERMIrNo. <br /> + <br /> EH 13-24 <br /> {HEV.rixsr / <br /> H 14.28 <br />