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0 <br /> �4. <br /> IS <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE:i STOCKTON, CA <br /> Telephone (209)'466-6781. <br /> PERMIT EXPIRES VYEAR 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 /> !� Cit % Lot Size 1 PM <br />' Job Address y } <br /> Phone <br /> Owner's Name ,V nd�_ -1,;;C"11,1111 <br /> �d �O� Address <br /> r `� 3 <br /> nn t <br /> Address b } License No.s. Phones x <br /> Contracto <br /> i TYPE OF WELL/PUMP: .NEW WELL ❑ WELL REPLAC MENT LJ DESTRUCTION ❑ <br /> s OTHER El <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO !NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> P INTENDED USE TYPE OF WELL ' PRO BLEM.ARI=k-•CONSTRUCTIONISPECIFICATIONS t ` <br /> ❑ Industrial ❑ Open Bottom Q Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> ❑ Domestic/Private LIGravel Pack /i - <br /> Tracy Type_of.Casing Specifications <br /> .❑ Delta Depth of Grout Seal ' Type of Grout <br /> l'1 Public (� Other <br /> ! Irrigation Approx. Depth 11 Eastern Sutfarce'Seal installed by� <br /> Repair Work Done ❑ Type of Pump H.P. _ ' State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material !top 501 \\ <br /> 1 Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ! REPAIR/AD DESTRUCTION l 1 alvailableseptic <br /> wi within 200 fee .) if public sewer is <br /> I !i <br /> i <br /> Installation will serve: Residence_ Commercial *j`Other <br /> Number of living units: Number of bedrooms x <br /> Character of soil to a depth of 3 feet: f,is�11a '� Water table depth <br /> r SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. F] , <br /> i+ Method of Disposal <br /> Distance to nearest: WellA Foundation Property Lineff!] <br /> LEACHING LINE ❑ No. & Length of lines ITotal lengthlsize ` <br /> FILTER BED ❑ 1t Distance to nearest: Well Foundation Property LineNon, e <br /> \\f <br /> SEEPAGE PITS l l DepthSize <br /> — <br /> SUMPS D ! Distance to nearest: Well j , Foundation 0 t Pro rty Line f <br /> i DISPOSAL PONDS O <br /> 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 /> i rules and regulations of the San Joaquin Local Health Ditrict. !j <br /> Home owner or licensed agarlt'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: "1 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." II <br /> The applicant ust call for all req d ' ctions omplete drawing on reverse side. <br /> pe <br /> Date <br /> Sig <br /> Title: r <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area a! <br /> �l <br /> i '1 <br /> i Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 !1 ❑ 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 /> FEE CK! RECEIVED BY DATE PERMIT'NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> :0-7 <br /> +.EH 13-24 IREV. <br /> EH 14-26 <br />