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APPLICATION FOR PERMIT <br /> SAN JOAQUIN'LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL TON 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 totheSan 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 City -,Lot Size PM <br /> Owner's Name Address 0 ---Phone) C q <br /> _Contracto�l?.k7,' a l � Address P', 061 " License <br /> TYPE OF WELL/PUMP= NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ , <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 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 /> ❑ Public ❑ Other s ❑ Delta Depth of Grout Seal Type of Grout 1 <br /> ❑ Irrigation ----Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done 9 <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') CA I <br /> Depth Filler Material (Below 501 [ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system'permitted if public sewer is N <br /> available within 200 fee <br /> Installation will serve: Residence ZCommercialOther- <br /> - - <br /> Number of living units:_J_ Number of edrooms ' ! r <br /> — - 5 <br /> Character of soil to a depth/�f 3 feet: �-�Water table-depth <br /> SEPTIC TANK Q Type/Mfg Capacity No. Compartments r12 IT I <br /> PKG. TREATMENT PLT. ❑ �--� Method of Dislposal Q_ <br /> Distance to nearest: Well Foundation Property.Line 1 j <br /> r I <br /> LEACHING LINE Z11 No. & Length of lines ``L-Ad� --- --'+otal length/size 6 T 1 <br /> FILTER BED 17 Distance to nearest: Well 'foundation Property Line <br /> [ SEEPAGE PITS ❑ Depth Size 2.x lL) Nu n r,"�' -'-2) <br /> [ SUMPS Distance to nearest: Well Foundation—t =iProperty Line ' <br /> DISPOSi,L.RdNDS to =C1. :--, rt ....€ ^- "-� i� I <br /> hereby certify that I have prepared this application and that the work will be done-in accordance with San Joaquiri"couhty_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 /> a v 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 /> {rg FThe applicant- st_call-for_ req 'red inspections. Complete drawing on ieverse side <br /> d a g <br /> i �- <br /> Signed j Title: Vs . Date: A <br /> /q FORIDE MENT USE ONLY f <br /> / <br /> Application A -- - ---- Date Areaccepted-byf ' <br /> I Pit or Grout Inspection by Date Final Inspection by I Date <br /> 1, Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Boz 2009, Stk., CA 95201 ' <br /> INFO AMOUNT DUE. AMOUNT REMITTED CASH ._ -RECEIVE0 BY DATE'. <br /> k �-PERMIT"N0, <br /> ! + EH 13-24[REV.;/a 5) <br />'I. EH 1426 <br />