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r APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA _ <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> f <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 S© oa .n <br /> Local Health District. 2 <br /> AI <br /> Job Address <br /> City ",4 Lot Size / a a�� PM <br /> ! <br /> Owner's Name <br /> Q Address �5 Phone <br /> a <br /> Contracts sii Address License No. Phone <br /> TYPE OF WELL/PP: NEW WELL ElWELL REPLACEMENT 71DESTRUCTION ❑ <br /> PUMP INST LLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST_ SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL R WELL PITS/SUMPS <br /> i <br /> INTENDED USE TYPE OF,WELL OBLEM AREA C UCTION SPECIFICATIONS <br /> Dia. of Well Excavation Dia. of Well Casing <br /> C] Industrial LI Open Bottom ❑ nteca <br /> Type + <br /> i ❑ Domestic/Private ❑ Grave! Pack 01Yp of Casing. _ Specifications <br /> 1-1 Public 1-1 Other CI Delta Depth of Grout Seal Type of Grout _— <br /> I I Irrigation --.Appy .. epth 1 1 Eastern Surface Seal Installed by <br /> ' State Work Done <br /> Repair-Work Done L7 Type o Pump z H.P. <br /> Well Destruction ❑ Well Diameter Sealing Mate ial I 6 501 <br /> DepthFiller Material (Below 50') -- <br /> TYPE OF SEPTIC WORK: NEW INS ALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> i 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: T '" Water table depth <br /> SEPTIC TANK '0(FType/f Ifg Capacity j�/wo 1N� No. Compartments <br /> A Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well !J Foundation 0D Pro erty Line <br /> LEACHING LINE . No. &Length of lines "4 Total lengt /size <br /> r <br /> FILTER BED ❑ Distance to nearest: Well Foundation �F r perty Line <br /> w <br /> SEEPAGE PITS I i Depth Size Number� - <br /> SUMPS ❑ Distance to nearest: Well Foundation Pioperty`zLine <br /> r <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 D,%trict. ; <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of theVork for which this permit is issued, I shall not <br /> 1 employ any person in such manner as to become subject to workman's compensatiori laws of California." Contractor's hiring or sub contracting signature <br /> I certifies the following: "I certify that in the performance of the work for which this permit is issued, I shalj{tmploy persons subject to workman's compensa- m <br /> tion laws of California." {+ ' l� <br /> The applicant m call for ail re fired inspections. Complete drawing on reverse side. <br /> r'r t <br /> T+tle: " .. 1 <br /> Signed )( i r�/ Date: <br /> FOR DEPARTMENT USE ONLY + <br /> v\}y! R <br /> Y- <br /> Application Accepted by pate `'� :' p'�9►rea *� "" � <br /> r Pit or Grout Inspection by Data Final Inspection,�y f Date <br /> S Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369421 ❑ Manteca 823-7104 ❑ Tracy8356385 ry y -4- <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave' ,0. 13.Z4009, Stk" A 95201 <br /> f - <br /> FEE <br /> INFO AMOUNT DUE 1`� �AMOUNTtREMITTED r K REC ED k3Y a DAT PERMIT NO. <br /> a.EH 13-24 iREV.1/H 5) <br /> EH 14-26 <br />