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i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �I 1601 E. HAZE I ON AVE., STOCKTON, CA <br /> i Telephone 12091 466-6781 <br /> IM PERMIT EXPIRES 'I'YEAR FROM DATE ISSUED <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 /> r 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. I` <br /> Job AddressCity Lot Size PM tom( <br /> Owner's Name Address 0 i d Phone -V(D�~ <br /> Contractor Address 7­��' 4t5, -k- 0 _License No.Y3610q4 Phone 3"y9/J <br /> TYPE OF WELL/P MP. i1 NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ))) <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS —+ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> [I Public f7 O`ther n Delta Depth of Grout Seal Type of Grout <br /> u <br /> I I Irrigation �IApprox, Depth l I Eastern Surface Seal Installed by <br /> - <br /> Repair Work bone ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well7biameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION P'A REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> IN available within 200 feet.) <br /> Installation will serve: Residence X Commercial Other <br /> Number of living units: —L-11, Number of bedrooms <br /> Character of soil to a depth o`f 3 feet: Se o �.., Water table depth <br /> SEPTIC TANK Q Type/Mfg Capacity aQ No. Compartments z. <br /> PKG. TREATMENT PLT. ❑ P�f Method of Disposal CSG `"t <br /> Distance to nearest: Well 100 T Foundation � - Property Line Z <br /> LEACHING LINE )d No. &Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well...`CIO Foundation �O r t` Property Line Z 5 F <br /> I <br /> SEEPAGE PITS ( I Dp pth Size Number <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ I' <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'i'signalure 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 /> I F <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X Tide: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Ir <br /> Application Accepted by Date Area <br /> .y <br /> Pit or Grout Inspection by i1hh Date Final Inspection by Date —Z <br /> Additional Comments: II' <br /> ❑ Stk 466-6781 ❑ Lodi Ili 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to:llIIEnvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> +.EH13-24tREV.tir551 0 Ca -.--70 v� r3go /Q_ <br /> EH 14-26 l/ ✓"l V _ ( �'�•.� "f IP✓ ,I <br /> x I� i <br />