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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES VYEAR 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. <br /> Job AddressCity Loirc <br /> �elF t Size PM <br /> Owner's Name 'E' �//,'4:• <br /> Address ' <br /> _ Phone <br /> „¢ ContraCtOf Qom♦ ,!/' <br /> {{ Address ��� ✓' / License No. ;2-Z 1/ phone <br /> TYPE OF WELL/ UMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST:SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> r o <br /> FOUNDATION `AGRICULTURE WELL OTHER WELL PITS/SUMPS_ <br /> INTENDED USE STYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca. Dia. of Well Excavation „ <br /> Dia. of Well Casing <br /> M ❑ Domestic/Private Q Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F1 Public C1 Other ❑ Delta Depth of Grout Seal <br />" } p Type of Grout <br /> I I Irrigation —.-Approx..Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br />' g Depth Filler Material {Below 501 <br /> I TYPE OF SEPTIC WORK: 'NEW INSTALLATION REPAIR/ADDITION .I 1 DESTRUCTION I I (No septic system permitted if public sewer is <br /> 5 available within 200 feet.) <br /> Installation will serve: Residence Commercial-cher <br /> Number of living units: ` Number of bedrooms <br /> r Character of soil to a depth of 3 feet: ^� Water table depth <br /> SEPTIC TANK <br /> ❑ Type/Mfg—ry: <br /> PKG. TREATMENT PLT, an i y No. Compartments <br /> El <br /> t <br /> .,t�pml� v 1� � Method of Disposal <br /> Distance to.neo e ��d�_ property Line <br /> !.- <br /> LEACHING LINE ❑ No. & Length o�fj t al length/size <br /> ❑ Di <br /> FILTER BED stance fo-nearVl a � <br /> o daFi flsi L Property Line ' <br /> SEEPAGE PITS ., Depth Size <br /> Nu bet', G✓� U <br /> k SUMPS E1 Distance to earest: We 1I Foundation 0 <br /> DISPOSAL PONDS ElPr°perry Line <br /> I hereby certify that I have prepared this application and that the work wAl be done in accordance with Sari 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 ce <br /> employ any person in such manner as to become subject trtfy that in the performance of the work for which this permit is issued, E shall not jfff <br /> o 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,.!shall employ <br /> S tion laws of California." persons subject to workman's compensa- <br /> tion <br /> wing on reverse side. <br /> The applicant must call for all required inspections. Complete dra <br /> j Signed X .. <br /> 1 Title: ' <br /> li UO PARTMENT USE ONLY <br /> Application Accepted 6y <br /> Date Area <br /> Pit or Grout inspection+by,.,_. <br /> —Date-----^----�= Final Inspection by Date <br /> Additional Comments: # <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 �"f7 Manteca 823-7104 ❑ 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 /> ' FEE •''AMOUNT DUE AMOUNT REMITTED <br /> ► �� <br /> [INFO RECEIVED BY DATE PERMIT NO. i <br /> +.EH 13-24IREV.�iH5] �� �, f•/.�,,17 .�.. _.-..-- __ y_��. �.— _.. _._... _. —7� ..„n +' a <br /> IEH 14-28 <br />