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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f � 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> i Telephone (209) 466-6781 <br /> :: . PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is heoeby 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 /> k Job Address City G Lot Size PM <br /> Owner's Name d Address .[r Phone $Sc5 p`Y <br /> Contractor r r Address • lf /1�j�lQ License No Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ �WEl_U REPLACEMENT EJDESTRUCTION ❑ i <br /> l, PCJ1i71P-INSTFfC'L7�7IOIV`❑ '' :SYSTEM'REPA9R-❑ -_ �, -— ..OTHER E7-._��___.; <br /> I� DISTANdE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUM}PS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA-TJONS-_-!�' Fes` <br /> ❑ Industiih.l ❑ Open Bottom ❑ Manteca Dia. of Well Excavation , Dia. of Well Casing <br /> IDDome$tic/,Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> i'I Public' ❑ Other ;�. f] Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.Q. { State Work Done_ <br /> Well Destruction ❑ Well Diameter 5e81ing Material /top 50'1 <br /> 3 Depth Filler Material (Below 50) { <br /> TYPE 4F'sSEPTIC WORK; NEW INSTALLATION REPAIR/ADDi`TION 1 1 DESTRUCTION I I (No septic system permitted 0 public sewer is <br /> 4 <br /> available within 200 feet.) b r <br /> Installafion will serve: Residence Commercial__ Other i <br /> t, Number of living units: __/— Number of bedrooms :- m r# •. 1' *� 'A, <br /> Character of soil to a depth of 3 feet: + Water table depth - <br /> SEPTIC TANK ❑ Type/Mfg 4-- Capacity G4 Na. Compartments <br /> PKG.. TMENT PLT. ❑ Method of Disposal i <br /> Distance to nearest: WellFoupdation Property Line <br /> LEACHING LINE +No. $ Length of lines.'^ ., / _ Total length/size ! <br /> FILTER.BED' Distance to nearest: WellFoundation F r . Property kine fJ 6 <br /> I r <br /> SEEPAGE PITS l l Depth Size i Number `• <br /> SUMPS ❑ Distance to nearest: Well Foundation' Property Line <br /> DISPOSAL PONDS ❑ t 1 <br /> I hereby certify that I have prepared this application and that the work_�will be None in accordance with San JoaZauin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health DiMrict. <br /> Horne owner or licensed agent's signature certifies the following: "I certify that in the perf8rmance of the work far 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 foriwhich this permit is issued, I shall employ <br /> tion laws of California." persons subject to workman's compensa- <br /> A f <br /> The applicant must calf fo II req 'red inspections. Complete drawing,on reverse side. .� <br /> Signed X. � j~.�_ <br /> 1 <br /> t Title: _ Date: <br /> i. FOR DEPARTMENT USE ONLY <br /> Application Accepted by }} DateS Area <br /> Pit or Grout Inspection by Date Final Inspection by Date �7 I <br /> Additional Comments: ; <br /> I-] Stk 466-6781 D Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6395 <br /> Applicant- Return ail copies to: Environmental Health Permit/Seryices 1601 E. Hazelton Ave„ P.O. Box 2003, Stk., CA 95201 <br /> CK <br /> + FEE AMOUNT DUE AMOUNT REMITTEI) RECEIVED BY <br /> +`EHY INFO CASH DATE PERMiT'NO. <br /> EH 11;28 -- <br />