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; - 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 Jdaquin 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. I! <br /> �V ]� <br /> fAddress k Flr L 7 City L Lot Size�50X �D PM <br /> I Job ryJA yy,+ <br /> r SI� � o fY � <br /> Owner's Name <br /> D Address Phone <br /> I ��tr l ,o Address Z-�a tL Lscense No. Phone <br /> Contractor <br /> TYPE OF WELL/PUMP: I! NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP I ALLATION ❑ SYSTEM REPAIR ❑ OTHE <br /> DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES DISPO POOP. LINE <br /> FOUNDATION AGRICULTURE WELL THER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PR EM AREA TRUCTION SPECIFICATIONS <br /> EDIndustrial ❑ Open Bottom ❑ Ma Dia. of Well Excavation Dia. of Well Casing r <br /> El Domestic/Private ❑ Gravel Pack Tracy Type of Casing— <br /> ..I. <br /> asing Specifications <br /> (I Public ❑ Other Fl Delta De f Grout Seal Type o1 Grout — <br /> I i Irrigation pprox. Depth l ) Eastern Surface Se- stalled by - 3 <br /> Repair Work Done r Type of.Pump H.P. State Work Done <br /> Well Destructio ❑ W61I Diameter Sealing Material (top 50') <br /> n1 Filler Material 1 Below 50') <br /> Depth _ <br /> k <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION { I REPA191ADDITION l 1 DESTRUCTION 94 fNo septic system permitted if public sewer is <br /> ai y A available within 200 feet.) <br /> k <br /> Installation will serve: Residence k, ,Commer Other 4 <br /> 0 <br /> Number of living units: <br /> 11 Number of bedrooms } <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> F <br /> SEEPAGE PITS I i Depth Size _ Number <br /> SUMPS Ll I!Distance to nearest: Well foundation Property Line <br /> F <br /> f <br /> ❑ <br /> DISPOSAL PONDS <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 gan Joaquin Local Health Diltrict. <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 /> 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 apPIIcan3,wMf1 call for atn,quir tions. Complete drawing on reverse side. <br /> Signed X <br /> Title: Date: <br /> I AV FOR DEPARTMENT USE ONLY <br /> d b Date Area <br /> Application Accepts y <br /> Pit or Grout Inspection by <br /> 1 <br /> 111 Dae Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369 621 ❑ 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 95201 <br /> CK FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By ATE PERMIT NO. <br /> INFO ,r <br /> 3 <br /> +.EH 13-24 IREV.i/K 51 3 , '�'+�' �. �VLI � <br /> L~ <br /> EH 14-28 '' <br />