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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 'I <br /> ~ 1601 E. HAZEL T ON AVE., STOCKTON, CA S.�k`Z � <br /> Telephone (209) 466-6781 C�eti h <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) Vot h�-tip r <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 /> "1i <br /> Job Address ��� �- V City Lot Size ,50 X/ 0 PM <br /> �s$�� �" Y <br /> Owner's Name l I dL VAddress S � Phone�C�7 ' �0 <br /> Contractor Address h-A'l E �r License No. Phone <br /> TYPE OF WELL/ UMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPO PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA STRUCTION SPECIFICATIONS <br /> El Industrial El Bottom ❑ M a Dia. of Well Excavation Dia. of Well Casing Vi <br /> ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications �} <br /> (l Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout--­ <br /> I <br /> rout _. 1 <br /> I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by _ <br /> Repair Work Do Type of Pump H.P. State Work Done_ <br /> Well De ction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION (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: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth c <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments J <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 /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ vvv <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 /> 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 applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: ��� �''� Date: �� ] <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date '�t <br /> Area ITT��� <br /> Pit or Grout Inspection Date Final Inspection by Q ate <br /> Additional Comments: I <br /> ❑ Stk 466-6781 O Lodi 369-3621 0 Manteca 823-71 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1 E. Hazelton Ave., P.O. Box 2009, Stk/, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> + EH 13-24(REV.tinsl 3 <br /> EH 14-28 ,v 0 U (-n <br /> � 1K6 �•lt, <br />