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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 -E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I' <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 /> T - - Size e�,®•G PM , <br /> Job Address yr City Lot <br /> (r Address Phone <br /> Owner's Name <br /> PhoneContractor r Address License No <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> + PUMP INSTALLATION ❑ — SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS w <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS w w <br /> ❑ Industrial C1Open Bottom E] Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack Cl Tracy ,_ :Type of Casing Specifications <br /> 1-1 Public H Other , ' 11,`. l_l'Delta" ,Depth of Grout Seal Type of Grout — <br /> J <br /> I I Irrigation --Approx..Depth .l.l Eastern Surface Seal Installed by_____L <br /> Repair Work-Done- '❑ Type of Pump`' H.P. State Work Done <br /> -Wdff Destr_uction­ ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material (Bolow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION' REPAIR/ADDITION l 1 DESTRUCTION t 1 INo septic system permitted if public sewer is <br /> / available within 200 feet.l , <br /> Installation'will serve: Residence Y ,Commercial Other j <br /> Number of living units: Number of bedrooms <br /> Character of soil to a dept 3 feat: Y C - Water table depth r <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ y, Method,of Disposal <br /> i <br /> •^-Distance to nearest: Well%.Foundation `Property Line <br /> LEACHING LINE No. & Length of lines GEzT� r Total length/size?Line <br /> FILTER-BED j (31- Distance to nearest: Well�( 1� Foundation r f Property <br /> u ' "" / �. _ - <br /> SEEPAGE PhTS i"I' Depth-- `S' Size .--�iu. Number <br /> ' ` �i(D/^"1` Pro <br /> SUMPS " Distance to nearest:, Well .Foundation perty Line <br /> DISPOSAL PONDS ❑ '- <br /> { hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinahces, state laws, and <br /> rules and regulations of the-San Joaquin Local Health District. � �.,. " _. <br />€ Home owner or licensed agent's signature certifiesAhe foliowirig:''`I certify that i Fthe performance of the work for which this permit is issued;i shall not <br /> k employ any person in such manner as to became subject to;workman's compensation laws of California."Contractors 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 parsons subject to workman's compensa- <br /> tion laws of California." �' s <br /> ll r <br /> The applicant.must call for all requir d inspections. Complete drawing,on reyerse side. -- <br /> Signed X_,,_�� i�___ ' <br /> Title: Date: . <br /> i FORD ARTMENT USE ONLY <br /> a t r �Q� .I <br /> Application Accepted;by Date A9 �d / Area <br /> 1,_ //'// <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 'i ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return alf copies to: Environmental Health Permit/Services 1601-E. Hazeiton Ave., P.O. Box 2009, Stk., CA 95201 <br /> f , <br /> AMOUNT DUE AMOUNT <br /> FEE .,REMITTED a CK RECEIVED BY DATE PERMIT NO, <br /> INFO CASH 1 c� <br /> a +.EH 13-24 IRE�V.r!n <br /> EH 14-28 1 !! <br /> r <br />