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>•r« r] APPLICATION FOR PERMIT •� - T <br /> v SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE:, STOCKTON, CAj <br /> Telephone (209) 466-6781 J <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �` r <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 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 /> 3 Job Address City Lor Size �s PM <br /> 1 <br /> Owner's Name L!� P$!c Address O O - /-yPhone " d'Z <br /> Contractor Address a License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ 'WELL REPLACEMENT •❑ DESTRUCTION ❑ <br /> PUMP INSTAL ON ❑ SYSTEM REPAIR C1 _ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE A <br /> FOUNDATION AGRICULTURE WELL gTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLE EA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Via. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Trac of Casing Specifications <br /> ❑ Public ❑ Other elta Depth Grout Seal ` Type of Grout ` <br /> ❑ Irrigation --Approx. D ❑ Eastern Surface Sea stalled by \ <br /> Repair Work Done ❑ Type of P p H.P. State Work Done t <br /> Well Destruction ❑ We iameter Sealing Material (top 501 / N <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial— Other i <br /> f ? <br /> Number of living units: Number of bedrooms ; <br /> Character of soil to a depth of 3 feet: i� � Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity---------1_J No. Compartments f ~ <br /> PKG. TREATMENT PLT. ❑ Method of Disposal' f <br /> i <br /> Distance to nearest: Well Foundati Property Line <br /> LEACHING LINE ❑ No. & Length of line Total length/size- - r <br /> FILTER BED Distance arest: Well Foundation Pro x <br /> party Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foun ion PropertylLine <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 IFF' <br /> rules and regulations of the San Joaquin Local Health District. <br /> Homeowner 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." 1 a <br /> Th a plica t must I for all req nspections. Complete drawing on reverse side. r . <br /> i i <br /> Sig ed Title: ���,+ <br /> Date: <br /> i <br /> FOR DEP RTMENT USE ONLY <br /> Application Accepted by Date r t Area <br /> Pit or Grout Inspection y f Date Final Inspection by pie <br /> I <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7164 ❑ 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. INFO CASH RECEIVED BY DATE PERMIT'N0. <br /> + EH 13-21 ft/es) r 347 i <br /> EH 1428 ' I CAM' t''i. <br />