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APPLICATION FOR PERMIT <br /> TSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA / <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES ]'YEAR FROM DATE ISSUED C(Ds � <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 /> 46Dp 7/ /� <br /> Job Address <br /> eLa _ City Lot Size oil G= PM <br /> Owner's Name t-r Address `�Q� � � Phone <br /> Contractor L -���'� '��P r <br /> AddressLicense No,C--� Phone <br /> TYPE OF WELL/PUMP: NE WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ,2 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0, OU11`4) <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD./� PROP. LINE`�lZ r <br /> FOUNDATION fi..— AGRICULTURE WELL laaL— OTHER WELL/40 PITS/SUMPS AV <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y oe— A.61.— <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca A� Dia. of Well Excavation Dia. of Well Casing <br /> Ll Domestic/Private ❑ Gravel Pack E3 Tracy Type of Casing Specifications <br /> 4`l Public AOther,60r1� F1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation'_ JCS �-Approx. Depth I 1 Eastern Surface Seal Installed by <br /> State Work Work Done <br /> Repair Work done ❑ Type of Pump H,P. <br /> Well Destruction ❑ Weil Diameter Sealing Material atop 501 <br /> Depth Filler Material iBelow 50') -- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIR/ADDITION I I DESTRUCTION I I iNo septic system permitted if public sewer is <br /> available within 200 feet.) \ <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal l <br /> Distance to nearest: Well Foundation Property Line ;. ;ri <br /> i <br /> � <br /> LEACHING LINE ❑ No. & Length of lines Total lengthisize` <br /> = <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property tine <br /> SEEPAGE PITS { I Depth Size _ Number "� *•t <br /> SUMPS L-1Distanceto nearest: Wel! Foundation Property Line <br /> DISPOSAL PONDS ❑ � w.. <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 /> 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 /> 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 lawsof lifornia." <br /> The applic must call all quire ctions. Complete drawing on rerse side. + _rfe : <br /> Signed Title: Date: <br /> FOR DEPARTM NT USE ONLY <br /> 1 <br /> Application Accepted by <br /> Krfte <br /> Date Area <br /> Pit or Grout Inspection by Date 3� p Final Inspection by Date 1* <br /> f Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> ♦.EH 13-24iREV.1/851 ?5?� <br /> EH 14-26 <br /> jr' <br />