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S- <br /> APPLICATION FOR PERMIT <br /> `. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> { Telephone (209) 466-6781 <br /> l PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1 (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 <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 7 4y. �. �G/ttL City Lot Size PM <br /> Owner's Name `Address Phone47,4*r <br />{ Contractor! <br /> I` Address1200 License No. Phone <br /> TYPE OF WELL/PUMP: NEW WECL'I�❑ ` `` WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> -- _ -.�, PUMP I_fV$TALLATIOIV � O� gYS_T,EM REPAIR.-❑_____ ,,,_,OT.HER_❑__ <br /> DISTANCE TO NEAREST: SEPTIC TANK EWER LINES DISPOSAL FLD. 1 PROP. LINE ~� <br /> F FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA GONSTRUCTION_SP-EGIFICATION5 {f <br /> ❑ Industrial ❑ Open Bottom ❑ Mantecaj Dia. of Well Excavation l 1 Dia. of Well Casing <br /> ,�bomestic/Private ❑ Gravel Pack El Tracy i �ype of Casing Specifications <br /> t <br /> LJ Public ❑ Other El Delta s Depth of q(ou}t�Sreal � i Type of Grout <br /> ❑ irrigation ---Approx. Depth <br /> .��-�'❑,3/EEa�astern �/} SealIl 11f led by I <br /> Repair Work Done ❑ Type of Pump H;P�4,,urface <br /> ! Staff Work OoneWel! Destruction ❑ Well Diameter_ , f Saling Maerial {top 50') <br /> Depth s Filler IMateria Below 5Q} ...__._ ­ &1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑'-F 'RUCTION 13 (No septic system permitted if public sewer is V <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commerci I1Qther <br /> Number of living units: Number of bedroo s :' <br /> Character of soil to a depth of 3 feet: I Water table depth <br /> SEPTIC TANK ❑ Type/Mfg 4 CapacityNo. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal i <br /> Distance to nearest: Well Foundation Property Line ii Z <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well _ Foundation---= --Property Line' <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Wel! Foundation Property Line <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 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."Contractors 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 applican o II rr spections. Complete drawing on/r/ed�ejrssee side, <br /> Signed Title:—�� Date: l <br /> Ag <br /> FOiPARTMENT USE ONLY <br /> Application Accepted by <br /> Pit or'Grout Inspection by Date Area <br /> rte, <br /> Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r <br /> FEE AMOUNT DUEAMOUNT REMITTED CA <br /> INFO SH RECEIVED BY HATE PERMITNO. <br /> + EH 4324(REV.1/e5) C.,0 G. <br /> EH 1428 (Q r"'U O 7 jjL <br />