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APPLICATION FOR PERMIT <br /> j SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE:ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> - PERMIT EXPIRES 1 YEAR 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 instal[the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance Na.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 /� ' l� rY Cit Lot Size PM <br /> Owner's Name ` Address ex Phone <br /> i <br /> -L-icense-No— Phon <br /> TYPE OF WELLlP NEW WE L WELL RE LACEME T D DESTRUCTION L1 r <br />' t PUMP INSTALLA ION SYST M REPAIR ❑ OTHER ❑ d�_ _ / <br /> 1 DISTANCE TO NEAREST: SEPTIC_TANK SEWER LINES r DISPOSAL FLO. PROP. LINE �P <br /> 1 e FOUNDATION AGRICULTURE WE CHER WELL Sgj. LPITS/SUMPS <br /> 4�INTENDED USETY -OF WELL' PROBtEMAREA CONSTRUCTION SPECwTC-' T NSA <br /> ❑ Indy rial Open Bottom ❑ Manteca Dia. of Well Excavation x Dia. of Well Casing <br /> t omestic/Private ❑ Gravel Pack . 0 Tracy Type of Casing Specifications <br /> if'1 Public Cl Other Cl Delta s Depth of Grout Sea{ , Type of Grout <br /> �i I Irrigation _--Approx. Depth I Eastern �'+ 'Surface Seal Installed by - <br /> -:Repair Work Done ❑ Type of Pump �_ H.P. ` r State Work Done ? V y <br /> ,.Well Destruction C] Well Diameter �r Sealing Materia!(top 501 f } <br /> i <br /> Depth <br /> f]Q� Filler Material (Below 50'1 <br /> ,TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION t I DESTRUCTION I I Wo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other r <br /> Number of living units: Number of bedrooms ' <br /> t Water 4able depth <br /> Character of soil to a depth of 3 feet: m., P <br /> :SEPTIC TANK- ❑ Type/Mfg Capacity No. Compartments <br /> ' :PKG. TREATMENT PLT. ❑ Method of Disposal �G] <br /> Distance to nearest: Well Foundation Property Line <br /> E x LEACHING LINE ❑ No. & Length of lines Total length/size <br /> (FILTER BED, ❑ Distance to nearest: Well Foundation Property Line yy= M <br /> -,SEEPAGE PITS'- CI Depth -Size ' Number <br /> ^!SUMPS_ ____-___LI Distance to nearest:,Well^. r F.oundation..r.------- _Property Line y <br /> DISPOSAL PONDS ❑ t G <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 4s . <br /> rules and regulations of the San Joaquin Local Health D3ttict. T. <br /> __ ., <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 4s to become subject to workman's compensation laws of California." Contractor's hiring or sub=contracting Signa_ <br /> icertifies the following: "I certify that the performance of the work for which this permit is'issued, I shall employ persons subject to workman's compensa <br /> tion laws of Calif lia." <br /> iL The applicant all f r a�lleirecl i pecjions. Complete drawing or erre ide. t <br /> Signed X Title: r Date: <br /> l t <br /> i a4F DEPARTMENT USE ONLY <br /> Application Accepted by Date 2�"` Area [ �� <br /> Pit or Grout Inspection by Date Z G Final Inspection by at <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 3621 C1 Manteca 823-7104 ❑ Tracy 835-6385 ' <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 20Q9 Stk', CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> - `+.,1H 13-241REV.1/N5] lA- <br /> 64'14.28 <br />