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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE 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 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 /> r <br /> ,k f <br /> Job Address _ � r rl 4 "`� City S44City Lot Size PM <br /> Owner's Name AddressPhone / -� Z) <br /> � Contractor �{r 1���r� License No. Phone <br /> i <br /> ' 7YPE OF WELL/PU NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> ' INTENDED USE TYPE 0;-NY&LL PROBLEM AREA CONSTRU TION SPECIFICATIONS <br /> ! <br /> El Industrial ❑ Open Bottom iVlanteca Dia. ofilM1leil Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tra �� ype of Casing Specifications <br /> M Public ❑ Other _ a to h.of Gro_tSal Type of Grout <br /> — <br /> Surface <br /> Irrigation —Approx. pth I I Eastern f�Surface Installed by - <br /> Repair Work Done ❑ Type of Pump /HH,P' State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [I REPAIR/ADDITION l I DESTRUCTION INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> i <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: 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 L-1 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 /> E 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 /> 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 app- nt m t if r all r air�din�spctis. Complete drawing on reverse side. <br /> I Signe Title: <br /> Date: <br /> i FOR DEPARTMENT USE ONLY <br /> Application Accepted b Date !� r // `� Area <br /> Pit or Grout Inspec / !1 Date Final Inspection by C. Date z S <br /> Additional Comments: <br /> �P/i.� <br /> i ❑ Stk 466-6781 ❑ Lodi 369-3 t ❑ Manteca 823-7104 Q 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 /> FEE AMOUNT DUE AMOUNT REMITTED CK. RECEIVED BY DATE PERMIT NO. <br /> INFO ffes�++ CASH <br /> + EH 13-241AEY.tiny v� tf�+ ( -^ wb_C[, -] <br /> EH 14-2a <br /> u <br />