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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i 1601 E. HAZEI_TON AVE., STOCKTON, CA <br /> I Telephone (209) 466-6781 <br /> i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I (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 /> i a-:�f" I S r , r. Ml City.. E� Lot Size U PM <br /> Job Address <br /> F <br /> Owner's Name �( �n -� - Address 5 G Phone <br /> r'!.w-abs.•...,r.rn+��+.r[.r..•.r.....�..:_.___�_..�_._..___.wy...,...•:`..�...w...r..w.+ .�. 'p _.-... -_. _,_„_;�.---+.� +,...-.`....:—.� ..w.!�.«-:•+.-...-. ....-� �-..._.�s;._�-- <br /> Contractor Address �{� )w t4 _ License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT. ❑4 r%s(' DESTRUCTION ❑ <br /> PUMP-INSTALLATION 71— "" SYSTEM REPAIR­❑'0--_ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULT ELL OTHER WELL PITS/SUMPS <br /> j INTENDED USE TYPE OF WELL PROBL REA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom anteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel.Pack ❑ Tracy Type of Casing Specifications T 1 <br /> ❑ Public C7 Ottier ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation pprox. Depth ❑ Eastern Surface Seal Installed by_- <br /> of <br /> Repair Work Done Type of Pump I } H.P; i r State Work Done <br /> Well Destructidn ❑ Well Diameter ; 'Sealing Material (tap 501 <br /> s <br /> ' Depth'' Filler Material (Belo 50'1 ' > r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ,.DESTRUCTION El (No septic system permitted if public sewer is <br /> available within 200-feeta- ' <br /> Installation will serve: Residence= ComMercial.._...,OthK. <br /> i, <br /> Number of living units:—I— Number of bedrooms <br /> Character of soil to;a depth of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg _ ,� -� 601392(# &- Capaci ) —No. Compartments <br /> PK-G. TREATMENT PLT. ❑'`l _ Method off Disposal <br /> it! {Distance fo'nearest>s Well�..�>� Foundatio `Q Property Line 7 <br /> LEACHING LINE ❑ No. & Length of linesjTotal length/siie <br /> FILTER BED [_1Distance to nearest: Well ��Foundation Pr.-FrtyLine <br /> � SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ 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 /> f 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 must call for all required inspections. Complete drawing on reverse side. <br /> kSigned Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by /f� _ Date ;�` Area_ <br /> Pit or Grout Inspection by D Fi al Inspection by Date P <br /> Additional Comments: r <br /> ❑ Stk 466-6781 ❑ L di 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-8385 <br /> `Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 - <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> + EH 13-241REV.1/851 <br /> EH 1428 666 <br />