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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 1 „Q@ <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 ' <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED !!! <br /> (Complete in Triplicate) <br /> ApplicationY <br /> is heieb 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 /> j/7p s �41 V City�ri /O"' Lot Size �'� X 99 PM <br /> Job Address f �/ <br /> 70 �jG E� Phone <br /> Owner's Namet/��t� f i I)SS Address <br /> i <br /> �E <br /> License NoPhone <br /> Contractor ,�� I Address Si�-."✓�� . <br /> TYPE OF WELL/PUMP:. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L1OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. _ <br /> FOUNDATION AGRICULTURE WELL OTHfR PITS_/SUMPS�� f <br /> INTENDED USE TYPE OF 'WELL PROBLEM AREA CONSTBIX41CrIT SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation T Specifications ' <br /> ❑ Domestic/Private ❑ Gravel Pack " ❑ a� �^- Type-of-Casing— " - <br /> ''" Type of Grout <br /> 1`i Public F I Other ❑ Delta Depth of Grout Seal - <br /> x. Depth l I Eastern Surface Seal Installed by - <br /> ri ation pro p r <br /> i l lr g <br /> i � H.P. <br /> M- ..'State Work Done <br /> Repair Work Done Type of Pump <br /> Well Des n ❑ Well Diamet;r Sealing Material op <br /> Filler <br /> I <br /> Depth Filler Material 18elow 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION t 1 DESTRUCTIO, 1 (No septic system permitted if public sewer is <br /> i v> a available within 200 feet.i <br /> Installation will serve: Residence 'I Commercial `^^Other <br /> Number of living units: _ Number of bedrooms. <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg Capacity_-. No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ I • <br /> Distance to nearest: Welt-""""=� Foundation Property Line r <br /> I Total length/size <br /> LEACHING LINE ❑ No. & Length of lines <br /> t FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> I r�" <br /> SEEPAGE PITS i I Depth`� Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> d that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application an <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, f 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." 1 <br /> I r <br /> i T licant m t call for a required inspec ions. Complete drawing on reverse side. <br /> Signed X Title: <br /> Date: <br /> *A FOR DEPARTMENT USE ONLY r1l\3rDat Area <br /> Application Accepted by <br /> `1a�� 7 <br /> Pit or Grout inspection Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 b Lodi 369-3621 ❑ Mante 823-7104 ❑ Tracy 835-6385 <br /> f Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 4 <br /> I FEEjjAIMAOUNT DUE AMOUNT REMITTED CK RECEIVED BY DA7PERMIT NO. <br /> INFO CASH ���TE <br /> G <br /> r + EH 13-24 <br /> EH <br /> 1/45) � �,. © oxri <br /> 07 <br /> i EH N-26 <br />