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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1 f 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> V Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate), .Q•�.1,..,t CL Nek <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. - a <br /> Job Address 'e� l <br /> City Lot Size PM <br /> Owner's Name 1lddress -7 ^G�� �s� e Phone "O O <br /> Contractor Address License No. Phone <br /> TYPE ELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REP ❑ OTHER ElDISTANCE TO N T: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> f NDATION AGRICULTURE LL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE ELL PROBLEM AREA ONST*UC ION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca a--I Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack a £ deo -C-esirtg� _. _.>_- v SgwiScations. <br /> ❑ Public ❑ Other el ta j Derpth of Grout Seal Type of Grout,t- <br /> O Irrigation <br /> ----Approx. Dept ❑ Eastern Surface Seal Installed by f! <br /> Repair Work Done ❑ Type of Pum H.P. _ State Work Done <br /> .Well Destruction ❑ Well Dia ter f Sealing Materia 501 1_ <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION_RqNo septic system permitted if public sewer is <br /> ailable within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of units: Number of bedrooms g <br /> Character of soil to a f 3 feet: ' Water table depth <br /> EPTIC TANK Type Capacity No. Compartments <br /> KG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance td nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Len t"of roes <br /> 9 Total length/size <br /> FILTER BED ❑ Distance to nee t: C-Wul�+•..ur..:_ ndation Property Line <br /> . EPAGE PITS ❑ Dept Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> SPOSALPONDS ❑ <br /> l -46reby 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 /> tr <br /> a and regulations of the San Joaquin Local Health District. <br /> tome 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 /> cbrtifies 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 /> ' e applicant must call for all required inspections. Complete drawing on reverse side. x <br /> �C %ned X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date � � Area ©� <br /> Pit or Grout Inspectio Date Final Inspection by Date <br /> Additional Comment <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ 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 /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT•'NO. <br /> + EH 3-24 1REV. <br /> EH 14-28 o <br />