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1 <br /> APPLICATION FOR PERMIT +' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 5209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) t' <br /> Application is heteby 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. y <br /> Job Address C �. t7 City Lot Size PM <br /> Owner's Name or- �� Address 175 / f/ L Phone �� 3 <br /> O <br /> Contractor_ &LI Address fZ icense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ L REP SENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION A AiR ❑ O <br /> DISTANCE TO NEAREST: SEPTIC TANK WER I DISPOSAL FLD. P P. LINE <br /> FOUNDATI N AG IC REQ OT. ELL. S/SUMPS <br /> INTENDED USE TYPE OF ELL RO L� RE N_• f ONAPEI 190 <br /> ❑ industrial ❑ Open Lott D eca�1/' , a, f e 1 Exc� t Dia. of Well Casing <br /> ❑ Domestic/Private ❑Grave acyTy�e sing / Specifications <br /> f l Public rt l O _ Delta Dep 1t o rou e I Type of Grout <br /> I f Irrigation FOX-([) th I I Eastern f� `!e Su a e el Install <br /> r v r 1 <br /> Repair Work Done ❑: T of P H State Work Done_ <br /> Jw <br /> Well Destruction ❑ Well is t Sei �f erial [top <br /> b <br /> r Depth Filler, aterial (Below 501 <br /> TYPE OF SEPTIC WORK: NSW INSTALLAT N 1.1 REPAIR'ADDITION N DESTRUCTION ( ] lNo septic system permitted if public sewer is 111���111 <br /> available within 200 feet.) <br /> Installation will serve: Residence_ CommercialOther r. <br /> Number of living units: Number of bedrooms_ <br /> Character of soil to a depth of 3 feet- Water table depth <br /> � <br /> SEPTIC TANK ❑ Type/Mfg L Capacity� 5 "uu No. Compartments <br /> PKG. TREATMENT PLT. ❑ i Method of Disposal <br /> Distance to nearest: Well Foundation Property-Line 1 <br /> i <br /> LEACHING LINE ❑ No. & Length of lines E Total length/size <br /> FILTER BED . ❑ Distance to nearest: Well „Foundation Property Line <br /> SEEPAGE PITS a I I Depth Size Number ! <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line I <br /> DISPOSAL PONDS ❑ I t . <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 Di%trict. <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, 1 shall not a <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- t <br /> tion laws of California." I I <br /> The applicant t call forrequired inspections. Complete drawing on reverse side. <br /> Signed X Title: _t }.CJk��� Date: r <br /> FOR DEPARTMENT USE ONLY a ` <br /> Application Accepted by 4 - t Date r A ea { <br /> Pit or Grout Inspection by / Date a Ins tion y Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 O i 369-362f ❑ Manteca 823-7104 ❑ Tray 835-8385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk:7 CA 95201 <br /> EE a <br /> INFO AMOUNT DUE AMOUNT REMITTED""! CASH RECEIVED By- /'�DATE- "" -PERMIT'NO. <br /> +.EHt3-241REV.t/H51 —16r.6v <br /> EH 14-26 <br />