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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL 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 Health District for a permit to construct and/or install the work herein described. This application is <br /> unty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin. <br /> made in compliance with San Joaquin Co <br /> Local Health District. s . <br /> City Lot Size a� PM <br /> Job Address <br /> - — <br /> Address _ Phone s <br /> Owner's Name <br /> {� Address i-� License No. u0bR1�1 Phone ICU <br /> Contractor PLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL RE OTHER ❑ <br /> PUMP INSTALLATION El SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �. <br /> Dia. of Well Casing <br /> Ll Industrial ❑ Open Bottom E3 Manteca Dia. of Well Excavation S ecifications <br /> F-) Domestic!Private Ll Gravel Pack ❑ Tracy Type of Casing p <br /> II 1'1 Public ;' ❑ Other Type of Grout Cl Delta � Depth of Grout Seal ; - <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by i <br /> H.P. <br /> State Work Done _ t <br /> Repair Work Done L3 Type of Pump �. <br /> i` Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Belo ') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i] REPAIRIADDITION ArDESTRUCTION I I availab <br /> septic system <br /> in rented if public sewer is <br /> � I <br /> Installation�will serve: Reside ce—st Commercial_. Other <br /> Number of living units: _V Number of b6edro ms J{ <br /> �i Character of soil to a depth of 3 feet:K Water-,table depth <br /> SEPTIC TANK CA-IlypelMfg /[� • �� e_ _ Capacity`,11 4p No.`Co r4im <br /> partents 2__ Lj] <br /> " Method-,of Disposal �I <br /> PKG. TREATMENT PLT. ❑ <br /> I Acb <br /> Distance to nearest: Well Foundation I Property tine; -' <br /> LEACHING LINE Pr- Nd. & Length of lines Total�lengthlsize <br /> - —. _r.._l..- <br /> Y FILTER BED,j ❑ Distance to nearest: We ��_ Foundation-4 f PropertyLine <br /> . SEEPAU'PITS l Depth y?' ��} ize <br /> ` '1-� Wejl ��b.f ,.Foundation :3'-Property Line <br /> SUMPS LlD+stance to nearest: <br /> DISPOSAL PONDS ❑.. -� �— <br /> I hereby certify that I have prepared this applic..atio'n'and�h'Pt'&workrwill be done in accordance with San Joaquin county ordinances state Laws, and <br /> rules and regulations of the San Joaquin Local FVealth d&r - _ <br /> !! Home owner or licensed agent's signature certifk.§thefollowing: "I certify that in the performance of the: o for,which this permit is issued, I shall not <br /> t employ any person in such manner as to I ecdrne subject to workman's compensation laws of California."' ont'ractor s hiring or sub contracting signature <br /> certi#res the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons,subjeect to work t an`s compensa- <br /> tion laws of California." ""�� ;/ t3# <br /> The applicant)must call for all quired inspections.YComplete drawing o reverse side, t °'�; <br /> ��,�[� Date:,, <br /> Signed,X a Title: <br /> FOR DEPAR fNENT USE ONLY <br /> Y = Date rea <br /> Application Accepted by ]i G <br /> 1 i Data Final Inspection by Date U <br /> Pit or rout.Inspection by <br /> Addhional Jrnments: <br /> 0 Stk 466 781 ❑ Lodi 369-3621 ❑ Manteca 823-71* L) Tracy 1335-6385 <br /> Applicant Riturn all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201_ <br /> FEECK- RECEIVED BY DATE PERMIT-NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> +.EH 1v24'�flEV.',t -H 51 t -� Y <br /> t EH 14-k i .y� CCC <br />