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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) 466-678.1 <br /> PERMIT EXPIRES T 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.649 for sewage or No.1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District.' <br /> Job Address / 0 7 lu. City ' Lot Size PM <br /> Address7U7 (.( <br /> Contracto4 Phone3� 7 CI o2 <br /> Owner's Name <br /> OZJAAAddress ` ' License No&)-.7� Phone 6 6^ger <br /> �'`"'l� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 <br /> PUMP INSTALLATION G�, SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGR LTYRE WELL ___._ OTIJER WELL PITS/SUMPS <br /> INTENDED USE TYPE OFIWELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> O Industrial 0 Open Bottom ❑ Manteca Dia. of Well.Excavation Dia. of Well Casing <br /> "omestic/Private ❑ Gravel P$ck ❑ Tracy Type of Casing Specifications <br /> M Public F1 Other Cl Delta Depth of Grout Seal ` Type of Grout <br /> I I Irrigation —..Approx. Depth I 1 Eastern Surface Seal Installed by - <br /> Repair Work Done L'f Type of PuMH•P• State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth — Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK:' NEW INS ALLATION 1.1 RI PAIR/ADDITION I I DESTRUCTION t'1 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ _ Other <br /> Number of living units: Nurhber of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> Water table depth <br /> s SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments O <br /> PKG. TREATMENT PLT.ElMethod of Disposal <br /> Distance to nearest: Well Foundation--r Property Line �J <br /> 3 , <br /> 3 LEACHING LINE O No. & LiDngth of lines Total length/siz <br /> x j <br /> FILTER BED O Distance to nearest;; Well " v "'Foundation T Props <br /> s l <br /> SEEPAGE PITS I1 Depth ' Size Number \FAQ e�_�ng� <br /> _. ___.. ____... _ ._ fw7 <br /> ®. SUMPS Ll -0istancd-Wrtear�t:__....-WLII Foundation�� Property Line to <br /> DISPOSAL PONDS ❑ v <br /> 1 hereby certify that I have prepared thjs application and that the work will be done in accordalnce vAth San Jooq t1y� to laws, and <br /> .rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signs re certifies the following, "I certify that in the performsnee of the work for which this permit is issued, I Mall not <br /> employ Y an person in such manner as to become subject to workman's compensation laws of alifornis."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 issu� ;I-shall employ persons subject to workman's campensa-" <br /> tion laws of California." n <br /> The applican must call for all required inspections. Complete drawing on reverse side. <br /> Signed X <br /> Date: 01 34 <br /> FOR EPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Duce Final Inspection by <br /> J <br /> Additional Comments: <br /> O Stk 466-6781 O Lodi 369-3621 O Manteca 823-7104 0 Tracy 835-t3365 <br /> Applicant--Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95MI <br /> FEE` AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> +.EH 13.24(REV.1/x 5) C-q <br /> EH 1426 <br />