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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 Joaqujn Local Health District for a permit to construct and/or install the work herein described. This application is s <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. /q <br /> City Lot Size <br /> Job Address /} _ r . ` / <br /> i` Phone C� <br /> -�``'Address <br /> Owner's Name (.� y� Q r� � j <br /> /� License No./ �_ !Y Phone)_ z' I <br /> Contractor! Address <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP,,INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICUL RE LL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA NSTRUCTION SPECIFICATIONS <br /> ❑ Industrial El Open Bottom ❑ Manteca ia. of Well Excavation <br /> Dia. of Well Casing <br /> Type of Casing Specifications <br /> ❑.DomesticlPrivate ❑ Gravel Pack LI Tracy Type of Grout <br /> f Public <br /> (7 Other n Delta Depth of Grout Sea! VP <br /> I I Irrigation At`j —..Approx. Depth I 1 Eastern Surface Sea! Installed by -H.P. State Work Done �f' <br /> r�f <br /> Repair Work Done L3 Type of Pump <br /> _ <br /> Well Destruction ❑ Well Diameter Sealing Material ftoQ 50'1 <br /> Depth Filler Material {Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I!r REPAIR/ADDITION 1.1 DESTRUCTION I I (No septic <br /> ilable system <br /> perm <br /> feetit'ed if public sewer is <br /> Installation will serve: Residence Commercial— Other �} <br /> Number of living units: Number of bedrooms -3- Water table depth <br /> Character of soil to a depth of 3 feet' ZQ [� No. Compartments <br /> SEPTIC TANK L3Type/Mfg Capacity <br /> ' Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> (} Property Line <br /> Distance to nearest: , ' Well�� Foundation. <br /> S Z TotM:16ngth/size r <br /> LEACHING LINE ❑ No. & Length of lines ,el <br /> Q � Property.Line <br /> FILTER BED Cl Distance to nearest: Welf" Foundation <br /> s <br /> i <br /> •-* Number l <br /> SEEPAGE PITS I I Depth 5 Size <br /> I' SUMPS ❑ Distance to nearest: Well Foundation/; - Property Line , <br /> t <br /> DISPOSAL PONDS ❑ <br /> ti <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 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 /> signature <br /> employ any person in such manner as to-become subject to workman's compensation laws of California."Coniraceonshiring <br /> subject to woorkmanlscompensa- <br /> certifies the following: '"I certify that in the performance of the work for which this permit is issued,I shall employ p 1 <br /> tion laws of California." <br /> The applicant ust call for al equired inspections. Complete drawing on reverse side. <br /> e. 06 <br /> Title: ^ r Date: <br /> Signed X <br /> t ,+ FO DEPARTMENT USE ONLY / ,Q <br /> Date <br /> / 0 — �" Area — <br /> Application Accepted by <br /> Pit or Grout Inspection by Date <br /> Final lnspectiori by <br /> 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. Box 2009, Silk., CA 95201 <br /> CK RECEIVED BY DATE PERMIT NO. <br /> FEE <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> + EH 13-24 1pEV.I/n 51 <br /> I EH 14-28 _ _ <br />