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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT {� <br /> 1601 E. HAZEL I ON AVE., STOCKTON, CA �{ <br /> Telephone (209) 466-6781 31,.4 V.r"r�17�., (� i <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED .�kw•e�.,�,7Cp <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 ,a <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 /> I Local Health District. <br /> Job Address i�C + }{ City Lot Size PM <br /> 4 <br /> Owner's Name dress z � Phone <br /> Contractor P Address License No. Phone <br /> ,TYPE OF WELL/PMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> LATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK LINES' DISPOSAL FLD. PROP. LINE <br /> FOUNDATION _ AGRICULTUR OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA TION CATIONS <br /> ❑ Industrial ❑ Open Bottom eca Dia" of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gr ❑ Tracy9 Type of Casing ecrfications <br /> 1-1 Public � Other Ll Delta, Depth of Grout Seal T.a of�Gre t <br /> i _ r .. <br /> I i Irri __Approx, Depth I I Eastern �5utiace Sual In by <br /> Repair Work Done ❑ Type of Pump Ft.P. State Work Done <br />( Well Destruction ❑ Well Diameter + Sealing Material Itop 501 <br /> Depth } Filler Material {Below 50'1 <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION {:1 REPAIRIADDITION l I DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.I <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number'of bedrooms -r <br /> Character of soil to a depth of 3 feet: _ Water table depth <br /> SEPTIC TANK Cl Type/Mfg Capacity No. Compartments <br /> „ PKG. TREATMENT PLT. ❑ [ Method of Disposal <br /> I 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 /> SEEPAGE PITS i I Depth Size _ Number <br /> SUMPS C1 Distance to nearest: Well Foundation Property Line <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 San Joaquin Local Health-District. <br /> I 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,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> i <br /> The li n must call a <br /> . PP q ired ins pectigws. Complete drawing on reverse side. <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date B—4� Area Q <br /> Pit or Grout inspection y� Date Final Inspection by Date <br /> Additional Comments: 61 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 C1 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 /> INFO AMOUNT DUE AMOUNT REMITTED AS RECEIVED BY DATE PERMIT"NO. <br /> ♦ EH1324{REV.,/x5) 2 43Q <br /> EH 14-28 <br /> i� <br />