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J <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T 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 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 /> Job Address f .� r�� Lot Size <br /> City s. 00 PM <br /> Owner's Name 544 —Address- � � ._�. ..--wrphone - r <br /> a <br /> A Contractor's Name "`"""'""""License No. yytf Ph <br /> one <br /> i TYPE OF WELL/PUMP: NEW WELL ❑- WELL REPLACEMENT ❑ <br /> DESTRUCTION ❑ S <br /> `I PUMP INSTALLATION ❑' ", SYSTEM REPAIR Q OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ' <br /> FOUNDATIONS--------- .AGRICULTURE WELL OTHER WELL PITS_ <br /> /SUMPS <br /> r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> ❑ Industrial ❑ Open Bottom`­. ❑ Manteca Dia.-of Well Excavation Dia. of Weil Casing <br /> El Domestic/Private ❑ Gravel Packer OeEl Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other 4~❑ Delta Depth of Grout Seal _ Type of Grout " <br /> • ElIrrigation _Approxi. Depth, ❑ Eastern SurfacerSeal=lnstalled by e t <br /> Repair Work Done ❑ Type of Pump - State Work Done { <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth �� ` -Ffil6!,Material {Belo 501 <br /> IE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION C] REPAIR/ADDITION" DESTRUCTION C1 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> t Installation will serve: Residence ' Commercial_ Other <br /> Number of living units: _ Number of_bedrooms.. <br /> r; Character of soil to a depth of 3 feet: C'.-4�>,_ ` Water table depth 6 A ' <br /> SEPTIC TANK ElType/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT:❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> 9 - <br /> LEACHING LINE No. & Length of lines Total length/size /D Jl <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth '2- Size Number <br /> SUMPS ; <br />�. r❑ Distance to nearest: Well AAA Foundation—/d' f Property 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 ordinances, state laws, and t <br /> rules and regulations of the'S'an Joaquin Local Health District. `F ' <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 i <br /> employ any person in such manner as to become 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,1 shall employ f <br /> tion laws of California." <br /> p y persons sybject to workman's compensa- <br /> The applicant call for all required ins ctio`ns�-Complete-drawing omrevers - fde, t ` <br /> Signed ? Title: Date: f <br /> FOR DEPARTMENT USE ONLY / <br /> Application Accepted by = <br /> Date <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> DateS— 7� Y <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3511 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 01 <br /> FEE AMOUNT DUE AMOUNT REMITTED m-CK# RECEIVED BY t' -DATE PERMITNO. <br /> INFO CASH <br /> t+ EH 13-24 1REV.10EH 14-26 <br /> 183E <br /> ° <br />