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- �: APPLICATION`FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ;} . <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> I Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> t (Complete in Triplicate) <br /> I <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 /> fE 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 /> Job Address t Cit Lot Size PM <br /> cl Jr nZ-3 <br /> 4 f <br /> Owner's Name. dress / Phone <br /> Contract Address License No tt PhoneO <br /> TYPE OF WELL/PUMP: W WELL ❑ WELL REPL CEMENT ❑ DESTRUCTION ❑ <br /> i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack-- ❑ Tracy Type of Casing - Specifications <br /> F1 Public n Other F.] Delta Depth of Grout Seal Type of Grout <br /> -- <br /> I Irrigation _-Approxi Depth I 1 Eastern Surface Seal Installed by <br /> - i <br /> Repair Work Dones ❑ Type of Pump H.P. - - State Work,Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 ' <br /> r Depth- Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1.) DESTRUCT IO (No septic system•permilted if�public sewer is f+-. <br /> available within 200 feet:? <br /> -- I ��. <br /> Installation will serve: s Residence i Commercial_ Other - , <br /> Number of living units: '- Number of bedrooms ; <br /> Character of soil to a depth of33 feet! Water table depth ` <br /> SEPTIC TANK ❑ Type/Mfg Capacity � k` No. Compartments r <br /> PKG. TREATMENT PLT..❑k-s t Method of Disposal <br /> Distance to nearest: Well Foundation Property Line . ' <br /> LEACHING LINE CI N6. & Length of lines Total Alength/size <br /> r FILTER BED '❑ sDistance to nearest: Well Foundation*--j' Property Line <br /> SEEPAGE PITS I I Depth j Size " Number <br /> by <br /> SUMPS Ll Distance to nearest, Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 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 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." Contractors hiring or sub-contracting signature t <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 laws of California." <br /> The applicant st call for all required inspections. Complete drawing-onrreverse side-=­—ai�; r <br /> Signed X <br /> 9 Title: a J Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date '' Area / <br /> Pit,or Grout Inspection by s Date Final Inspection by Date!--.? d / <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 <br /> ...Applicant---Return-all-copies-tor Environmental•Health-P-ermit/ServicesA601_E...Hazelton.Ave;=R.-Q:-Box 20091�Stk;_CA.,95201= <br /> ' � t <br /> FEE ,r✓Y �f 4 <br /> INFO AMOUNT DUE-it �' AMOUNT,REMrF ED_ CASk� REC_IV -BY S` :DATE PERMIT'NO. <br /> r EH 13-24(REV. <br /> —EH.1A•29 -,•-aT <br />