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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. H_AZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 y R <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) w <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 i <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 <br /> City Lot Size O x / PM <br /> _, � � .•".� S.. ._ -. ' <br /> Owner's Name Address.-,, Phone <br /> `,-> 1 " ; <br /> Contractor address License No.L �3 " Phone <br /> TYPE OF-WELL/PUMP: NEW WELL ❑ _ WELL REPLACEMENT ❑ DESTRUCTION ❑4 u <br /> t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER�0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE a <br /> j FOUNDATION AGRICULTURE WELL OTHER WELL PITS/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 /> ❑ � i <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> . <br /> R: - �---^—' ". "_`""...--""'""..�....._— .� TT of Grout <br /> [i] Public. ❑ Other [I Delia- Depth of Grout Seal YPe r <br /> ❑ Irrigafion . -Approx. Depth ❑ Eastern Surface Seal Installed by— <br /> I <br /> Repair Work Done C1 Type of Pump H.P. State Work Done <br /> .V11 <br /> Well Destruction ❑ Well Diameter Sealing Matenai (top 50') <br /> IDepth' - I filler Material (Below 501 } <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ D TRUCTION ❑ (No sela pti system <br /> emitted if public sewer is <br /> Residence_ Co I merciai— Other . r r }� <br /> Installation will serve: Res l r <br /> Number of living units: Number of bedrooms x r �Water table <br /> Character of soil t la depth of 3 feet: <br /> _1 -x A J.;. ble depth <br /> I No. Compartments ' v <br /> SEPTIC TAMC � E] Type/Mfg Capacity—-act�' <br /> { PKG. TREATMENT PLT. ❑ Method of Disposal 4 A <br /> j <br /> Distance to nearest: well Foundation Property tine <br /> e " <br /> LEACHING LINE 11 No. length/siz <br /> No. & Length of lines � <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line } ' <br /> SEEPAGE PITS EJDepth Size Number ° <br /> SUMPS ❑ Distance to nearest:—Well-w---- —Foundaton-:�--•Property-Line� ! <br /> DISPOSAL PONDS ❑ 1 <br /> 1 hereby certify that 1 shave 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." Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which thii permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." 1 $ <br /> The applicant <br /> us ce11 for required inspections. Complete drawing on reverse side. A <br /> IDate: `/ 7 <br /> Signed ° Title:' <br /> !� 3_U43 7 <br /> DEPARTMENT USE ONLY i� <br /> 01 <br /> Application Accepted by ``---��` 4—abate Area Y <br /> Date Final Inspection by 4011Date <br /> Pit or Grout Inspection by <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 2009, Stk., CA 95201 <br /> 4 <br /> h_ FEE 'AMOUNT DUE AMOUNT REMITTED ° "CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> + EH.13.24IREV.r/85) * 2/y3/ 7 <br /> EH 14-28 <br />