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si-- <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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 desc ibed. 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 /> Job Address City Lot Size ��- ��d� PM <br /> Owner's Name Address e�, t.— =_ Phone <br /> Contractor _ Address �1 License No. Phone ' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SE ES ISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGR CULTUR ELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONST ON SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of ell cavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Grave! Pack - 0 Tracy Type f Casing Specifications <br /> f] Public ❑ Other F I Delta D th of Grout Sea Type of Grout <br /> I Irrigation —.Approx. Depth I I Eastern 1 urface Seai Installed b <br /> Repair Work Done ❑ Type of Pump H.P. Sta Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50') j <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADOITION I I DESTRUCTION INo septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other' <br /> Number of living units: --t– Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth 1 <br /> SEPTIC TANS Kw^__""r"'r_ Type/Mfg <br /> Capacity No. Compartments <br /> PKG. TREA�TMEN&PLT. ❑ � Method of Disposal <br /> _ <br /> I <br /> Distance to nearest: Well Foundation Property Line I <br /> LEACHING�LINE ❑ No. & Length of @ries Total lengt1. <br /> h/size <br /> FILTER BED ❑ Distance to nearest: Well FoundationProperty Linea t <br /> SEEPAGE-PITS—r I'] Depth Size i A. Number i <br /> SUMPS C1 Distance to nearest Well f Foundation Property Line <br /> DISPOSAL PONDS ❑ # A <br /> I hereby certify that I have prepared this application and that the wark`will be done in accordance wit 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 cerci#les the following: "I certify that in the performance of the work for which this permit is issued;_I-shall not <br /> ..employ any person inisuch 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 ust a11` ire pei% • Complete Arawing_on reverse-side.–,,J � <br /> Signed X Title: <br /> Date:��-'� <br /> DEPARTMENT USE ONLY {` <br /> Application Accepted byDate i ^.L-7 Area <br /> Pit or Grout Inspection b Date Final InSPOCUDngy-77 Date =G� <br /> Additional Comments: .�c�im <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manfeca 623 7104 ❑ racy 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 RECEIVED BY DATE PERMIT'Np. <br /> INFO ASH <br /> + EH13-21[REV.riKsl �r7� ! Is <br /> EH 14-26 1 .C1 tJ 1-0 -26-9-7T 3& <br />