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APPLICATION FOR PERMIT '- <br /> �� ( SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA /1"h 6-&A� <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , <br /> -(Complete in Triplicate) 1 <br /> 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 di <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 /> AAJob Address ZU1City Lot Size PM <br /> r <br /> Owner's Name' `*- Address Phone <br /> >, �. <br /> -V <br /> r vI <br /> Contractor AddressZ704&dLicense No ����, Phone <br /> TYPE OF WELL/PUMP:' " '"NEW WEL17❑—WELL-REPLACEMENT-0^^"' ''—DESTRUCTION-171 i, <br /> _ PUMP INSTALLATION L1 SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC,TANK SEWER LINESDISPOSAL FLD. PROP. LINE <br /> i FOUNDATION" AGRICULTURE E OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA COIIYTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca " D' of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy y of Casing .A Specifications <br /> l`1 Public ❑ Other ❑ Delta De th of Grout Seal, f Type of Grout <br /> I I Irrigation.�—._—.---Approx..,Depth_I.1...Eastern, _ _S dace-Seal Installed by A <br /> Repair Work Done 13 Type of Pump H . State Work Done <br /> Well Destruction ❑ Well Diameter ealing Material (top 50'1 <br /> s Depth Filler Material (Below 50') <br /> TYPE OF,SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION I I DE TRUCTION l I INo sept system permitted if public sewer is <br /> ' availabl within 2 feet.) <br /> Installation will serve: Residence Commercial Other 2 <br /> 4V , <br /> Number of living units:7 "- Numf ef'of bedrooms 1 r <br /> Character of soil to a depth of 3 feet: w '?' I ' �Weter table depth <br /> SEPTIC TANK ❑ Type/Mfg v Capacity '. No. Compartments <br /> PKG. TREATMENT PLT. ❑ i, Method of Disposal <br /> t ! Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines I Total length/size j <br /> FILTER BED O Distance to-nearest,—Wellndation'- Property Line <br /> M SEEPAGE PITS i I Depth 1 Size Number <br /> SUMPS ) ❑ Distance to nearest: Well _ _ -Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> r t <br /> I hereby certify that l have prepared this application andithat 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. W <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 becnma subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature 1 <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 applica must cal all require nspections.-Corn ate drawing on reverse side. <br /> _ s.�*_ <br /> Signed X Title: __ bate: <br /> -- `` FOR DEPARTMENT USE ONLY <br /> Application Accepted by r Date <br /> j <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 <br /> FEE -' AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY pATE PERMI7_,NO. — <br /> INFO _CASH __.— - —�.• .— <br /> a E13-24IREV.tiM 51 <br /> EH <br /> 14-26 <br />