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APPLICATION FOR PERMIT <br /> SANSJOAQUIN LOCAL,HEALTH DISTRICT + <br /> 1601,,E. HAZELI ION AVE., STOCKTON, CA ; <br /> Telephone 52091 466-6781' <br /> PERMIT EXPIRES1 YEAR FROM DATE ISSUED <br /> 1[' (Complete in Triplicate),.., � .& " � Y <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 /> 7 rt, <br /> Lot Size PM <br /> Job Address <br /> Address - T _.Phone !" <br /> Owner's NameAtf��l <br /> t <br /> Contractor's Name <br /> nse Na. y Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION 1`7SYSTEM REPAIR 13 OTHER Q <br /> [ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> E FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ industrial El Open Bottom Q Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> T of Casing Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type Type of Grout <br /> ❑ Public ❑ Other 11 Delta Depth of Grout Seal YP <br /> El Irrigation �ApP <br /> ' rox. Depth ❑ Eastern Surface Seal installed by <br /> Repair Work Dane ElType of Pump - H.P. State Work Done <br /> Sealing Material (top 50'1 S <br /> Well Destruction ❑ Weil diameter 9 <br /> Depth Filler-,-Material-(-Below-W) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION Ll DESTRUCTION Elallo septic ihite20permitted if public sewer is <br /> feet.i <br /> { r� <br /> Installation will serve: Residence--'Commercial —Other *� <br /> t I -� <br /> r Number of living units: 1 Number of bedrooms <br /> e-". A I Water table depth <br /> Character of soil to a depth of 3 feet: fp <br /> SEPTIC TANK Q Type/Mfg t Capacity_— No. Compartments <br /> PKG. TREATMENT PLT..-d t �J °� 6�^ �""— "" J'�Method of Dispasa! <br /> 1" lu Pro e Line Q <br /> Distance to nearest: Well foundation� P rtY <br /> Total,length/size'' <br /> LEACHING LINE ❑ No. & Length of lines . —�—�� � . r <br /> t <br /> FILTER BED ❑ Distance to nearest: Wel! oundation Pr6perty ne <br /> ' 4 <br /> Number <br /> SEEPAGE PITS E3Depth Size <br /> ` <br /> SUMPS El Distance to nearest: Well TundationProperty FineiDISPOSAL PONDS ❑ I <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 /> t 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 work1or 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."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,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all d inspections. Complete drawing on r se side. <br /> Signed <br /> C Title: Dat <br /> f FOR DEP E USE ONLY r <br /> Application Accepted by <br /> Date � ,v � rea <br /> �/ ti� rL <br /> Pit or Grout Inspection by Date / C� Final Inspection by a Date. <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi! 3t�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, Stk., CA 9.5201 <br /> f <br /> 2 <br /> FEE CK RECEIVEEBY <br /> GATE PERMIT"NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> +EH 13 <br /> -24(REV.10!831' ^� •� S �� .!r'`S <br /> EH 14-25 <br />