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APPLICATION FOR PERMIT <br /> O 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 /> 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 j <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 /> s .k [ I <br /> 'Job Address @Q.c City Lot Size___. � �^'�"f'�► <br /> Y <br /> '! l� I <br /> Owner's Name j R s , AddressPhone <br /> f <br /> Contractor ddress License No. .14s{l Phone <br /> TYPE OF WELL/PUMP: NEW WELL L1 WELL REPLACEMENT DESTRUCTION ❑ + <br /> PUMP INSTALLATION/' -"SYSTEM'REPAIR'❑"'" """— -OTHER'❑ <br /> , � <br /> DISTANCE TO NEAREST: SEPTIC TANK ImoSEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> i <br /> 'Domestic/Private ❑ Grave! Pack LlTracy Type of Casing Specifications <br /> f'1 Public f 1 Other Cl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _.-Approx. Depth l I Eastern Surface Seal installed by - <br /> Repair Work Done ❑ Type of Pump Ila H.P. State Work Done <br /> Well Destruction ❑. Well Diameter Sealing Material Itop 50'1 <br /> Depth Filler Material IBelow 501 -- t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 'REPAIR/ADDITION ( 1 DESTRUCTION I I lNo septic system permitted if public sewer is UU <br /> hf available within 200 feet.) <br /> I s { • S k' 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: ` A`' T— Water table depth <br /> f <br /> SEPTIC TANK t i7, Type/Mfg Capacity •'�' No. Compartments <br /> PKG. TREATMENT PLT- ❑ t - Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total'lengthlsize <br /> FILTER BED ❑ Distance to nearest: Wel! Foundation Property Line <br /> SEEPAGE PITS l 1 DepthLL Y Size Number <br />+ SUMPS Cl Distance to nearest: Well Foundation Property Line' <br /> DISPOSAL PONDS ❑ y <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 or all re red inspections. Co plate drawing on reverse side. I <br /> t <br /> Signed X Title: 42 do 0-1 46E Data: <br /> FOR DEPARTMENT USE ONLY f'} <br /> Application Accepted by Date Area v <br /> Pit or Grout Inspection by Date Finai Inspection by �?h Dat�p- <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 Cl 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 95201 p <br /> 1 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT*NO. <br /> INFO CASH <br /> +.EH 13.24 IREV.i/n 51 <br /> EH 14-2e <br />