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4: <br /> APPLICATION FOR PERMIT <br /> " SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED­, <br /> lComplete 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 17 Z /1Z ry —"City C11' . �ot Size PiVI <br /> Owner's Name r dress J7~3 ' A,,IZ Q- Phone <br /> Contractor Address License No. Photie_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> UMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I <br /> DISTANCE TO NEAREST`. SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LIN }I <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCIFICATIONS i <br /> i ❑ Industrial ❑ Open Bottom ❑ Manteca ta. of Well Excavation Dia. of Well Casing ,. <br /> ❑ Domestic/Private ❑ Gravel Pack y Type of Casing Specifications { <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 1 <br /> ❑ Irrigation prox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. State Work Done <br /> Well Destr n ❑ Well Diameter Sealing Material stop 50'I t <br /> Depth Filler Material iBelow 501 <br /> PE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> <'d available within 200 feet.) <br /> 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: v Water table depth <br /> SEPTIC TANK Type/Mfg Capacity ­No. Compartments <br /> PKG. TREATMENT PLT. ❑ I Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size f <br /> FILTER BED ❑. Distance to nearest: well Foundation ` `` Property Line <br /> 9 I � <br /> SEEPAGE PITS ' ❑ Depth Size Number <br /> I SUMPS ❑ Distance to nearest: Well- Foundation* ^ - Property Line <br /> y DISPOSAL PONDS ❑ <br /> fl I hereby certify that I have prepared this application and that the work will be done iri 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 whicti 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 a licant must cgil for all required inspect' Complete drawing on reverse side. ¢ <br /> Signed X Title: a'SCA Date: �';1LVA <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 1 `� f Area <br /> Pit or Grout Inspection Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mant 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 /> _ t <br /> r ` <br /> FEE r.AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> I INFO <br /> t <br /> r EH 13-24 CR 1/8 5) �S ki <br /> Loi�_ tib. <br /> EH 14-28 - <br />