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APPLICATION FOR PERMIT <br />` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ` 1601''E-HAZEL l ON"AVE., STOCKTON, CA <br /> .Y Telephone {209) 466-6781 <br /> F - - -y + PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> i <br /> 5 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 /> I 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. C) <br /> 1 L E City PM <br /> PM 5 <br /> Job Address 1 <br /> one <br /> Owner's Name <br /> Contractor L ddress 2 License No. Z Phone <br /> } �t a-TYPE OF WELL/PUMP: N WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION [>� SYSTEM REP!IR ❑ OTHE <br /> DISTANCE'TO NEAREST: SEPTIC TANK WER LINES f -n DISPOSAL FLDWO-P. LINE <br /> I I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ©� <br /> INTENDED USE <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fl <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Type of Casing— C. Specifications bin-�_�`,_, <br /> ❑ 0 esticlPrivate ravel Pack ❑ Tracy <br /> ublic ❑ Others �elta Depth of Grout Seal Type of rout <br /> ❑ Irrigation [�pprox. Depth ❑ stern k Surface Seal Installed by , <br /> Repair+Work Done El Type of Pump _5� H,.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> r is <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION.❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ sstine20m <br /> feet yed if public sewe11 <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units:13• +(Number of bedrooms <br /> Characf soil to a depth of 3 feet: <br /> - - Water.�table depth <br /> ter o <br /> i ° Capacity No. Compartments ' <br /> SEP,TRIC TANK ❑Type/Mfg # <br /> PKG. TREATMENT PLT. 1-11 Method of_Dispvsal "� t <br /> } Distance to nearest: Well ti Foundation Property Line ^' v <br /> LEACHING LINE C1No. & Length of lines `. Total length/size <br /> .' f PrLie r ; J <br /> FILTER BED ❑ Distance to nearest: Well Foundatidn 1. <br /> $ <br /> SEEPAGE PITS ❑ Depth Size j Number . ` <br /> Property Line � -- � <br /> SUMPS ❑ Distance to nearest: Well Foundation �} a y <br /> DISPOSAL PONDS ❑ i - <br /> hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin'county ordinances, state laws, an <br /> t rules and regulations of the San Joaquin Local Health District j `-' I <br /> k Home owner ansa nt's signature oertifies the following: "I certify that in the performance of the work for which-this permit is issued, I shall not <br /> employ an arson in such nner as to become subject t orkma 's compensation laws of California."Contractor s hiring or sub contr"aching signature <br /> certifies a following: "I ce that in the performa ce th work or which this permit is issued,1�sha11 employ.persons subject to wvrkma s'compensa- <br /> tion 1a of Califo nia." @ O <br /> The <br /> .plicant u r all req ed in 1awing on r s' e. •r j- <br /> i <br /> Title: Date <br /> Signed . / <br /> R DEPARTMENT USE ONLY <br /> f <br /> 1 f <br /> Application Accepted <br /> Date f- 6 Area 3 <br /> Pit o Grout 1 pecti y <br /> ate al Inspection by Date /$? <br /> Additional Comments: <br /> ❑ Stlt 466-fi781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CK RECEIVED DATE PERMIT"NO. <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> + EH 13-24(REV.1/85) O S <br /> EH 14-2a <br />