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APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZE 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 HeSlth District for a permit to construct and/or install the work herein described. This application is <br />made in compliance with San Joaquin County Ordina No. 549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin <br />Local Health District. <br />City - ^Lot Size �- PM <br />Job Address <br />Owner's Name Address Phone <br />Contractor <br />!f,-,�' <br />Address- a�ri License NoPhone <br />TYPE OF WELL/PUMP: NEW WELL ❑_ ' WELL REPLACEMENT © DESTRUCTION ❑ <br />'""""""-'"-"-" .—PUMP INSTALLATION ❑� 1 FSYSTEM- REPAIR -C ''-"'"""'""'""' OTHER LI ­ <br />DISTANCE <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br />-FOUNDATION AGRICULTURE WELLOTHER WELL PITS/SUMPS <br />Ulf" M61:1 GO RV <br />0 Industrial - <br />© Domestic/Private <br />F1 Public <br />I I Irrigation <br />Repair Work Done ❑ <br />Well Destruction ❑ <br />TYPE OF WELL <br />❑ Open Bottom <br />❑ Gravel Pack <br />0 Other <br />_..Approx. Depth <br />Type of Pump <br />Well Diameter <br />Depth <br />TYPE OF SEPTIC WORK: NEW INSTALLATION <br />PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />❑ Manteca Dia. of'Well Excavation Dia. of Well Casing <br />❑ Tracy Type of Casing Specifications <br />❑ delta Depth of Grout Seal • Type of Grout <br />I I Eastern Surface Seal Installed by <br />H. P. <br />^ Sealing Material (top. so'), <br />Work Done <br />REPAIR/ADDITION I DESTRUCTION I i (No septic system permitted if public sewer is <br />available within 200 feet.) <br />Installation will serve: Residence_ Commercial _ Other,— <br />Number of living units: E Number of bedrooms <br />Character of soil to a depth of 3 feet: b -a -_ -- Water table depth <br />SEPTIC TANK Type/Mfg 'Ilo Capacity_ No. Compartments _ <br />PKG. TREATMENT PLT. ❑ ~ Method of Disposal . <br />F Distance to,n arest: Well Foundations Property -Line ___I_D0___.,` <br />LEACHING LINE <br />FILTER BED.. <br />SEEPAGE -PITS <br />SUMPS <br />DISPOSAL PONDS 1 <br />Length of lines <br />E) Distance to dearest: <br />!t l Depth <br />A , <br />Ll Distance to nearest: <br />Well Mot <br />Size - <br />Well <br />" <br />Total length/sizea-7 6_ <br />Foundation �s / -Property Line <br />Foundation <br />Number <br />Property Line <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 for all req 'red ' spec. ions. Compiete,:drawing on reverse side. <br />Signed X Title: Am Date: <br />FOR DEPARTMENT USE ONLY <br />Application Accepted by Date ( Area <br />Pit or Grout Inspection by Date Final Inspection by�/ DateJ� I� <br />Additional Comments: <br />❑ Stk 466-6781 Q Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br />Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 <br />4' x <br />i <br />i <br />a EH 13-24 )REV. t / 11 51 <br />EH 14-26 <br />INFEO <br />AMOUNT DUE <br />AMOUNT REMITTED <br />CAS 11 <br />RECEIVED BY <br />DATE <br />PERMIT'NO. <br />`x`70 <br />_ <br />"A /%S <br />gs�s-3pto. <br />I <br />7, <br />