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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> �q 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 /> 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. g <br /> Job Address <br /> City Lot Size PM <br /> Owner's Name <br /> Address <br /> Phone <br /> Contractor's Name License No. /Q In <br /> se <br /> OF WELL/PUMP: Phone <br /> NEW WELL LJWFLL REPLACEMEN 2 DESTRUCTION ❑ M <br /> PUMP INSTALLATION ❑ . SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES I �Q <br /> DISPOSAL FLD. PROP. LINE .� <br /> FOUNDATION AGRICULTURE WELLOTHER WELL ' SPITS/SUMPS �f <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation + <br /> Dia. of Well Casing <br /> ❑ Domestic/Private (� <br /> ❑ Grave! Pack ❑ Tracy Type of Casing <br /> ❑ Public ❑ Other Specifications <br /> ❑ Delta Depth of Grout Sea! <br /> ❑ Irrigation �""�"'" � - Type of Grout <br /> .—Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. <br /> Well Destruction Eleter <br /> Wel! Diameter <br /> State Work Done <br /> Sealing Material (top 50') N <br /> Depth Filler Material (B-;1o,,750') f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION jT7REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) 1 <br /> Installation will serve: ResidenceCommercial i Other <br /> Number of living units: ' Number of bedrooms - s <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANKt Water table depth <br /> ❑ Type/Mfg �" Capacity No. Compartments (� <br /> PKG. TREATMENT PLT. ❑ ; -t5 . % � <br /> tt Method of Dis osal (� <br /> Distance to nearest: Weil .o �+ undation Property Line <br /> LEACHING LINE A' No. & Length of lines j) IQ <br /> FILTER SED Total length/size <br /> ❑ Distance to nearest: Well FounS <br /> �.-��� dation_.�Q_ property Line <br /> SEEPAGE PITS Depth �~ Size A <br /> � _ r' <br /> SUMPS E3 Distance to nearest: Well Number <br /> '} <br /> DISPOSAL PONDS ❑ -��L� Foundation 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 m st call for all require ' pections. Comple drawing on rev a side. <br /> Signed �j <br /> Title: Date: GG <br /> FOR DEPARTMENT USE ONLY 4 <br /> Application Accepted by Date y <br /> Area <br /> Pit or Grout Inspection by <br /> Additional Comments; pate Final Inspection by <br /> Date <br /> ❑ Stk 466-6781 IX Lodi 389-3621 ❑ Manteca 823-7104 El Tracy 835.6385 + <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9520 � � <br /> e.later tv west-c*.d -f- <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFODUE <br /> RECEIVED 8Y DATE PERMIT`N0. <br /> +Eli 13-24{REV. 10!831 <br /> EH 1426 I•L ��fL � fG,�C(y (Yi j <br />