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APPLICATION FOR PERMIT ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t n <br /> 1601 E. HAZEL i ON AVE., STOGKTON, GA 1 �c•••� i� <br /> Telephone (209) 466-6781 l p <br /> ,PERMIT EXPIRES 1,YEAR FROM DATE ISSUED <br /> I <br /> (Complete in Triplicate) <br /> I t application is <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 app <br /> made in compliance with San Joaquin Co�my 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 /> u J City of Size <br /> !Ut/� ! PM <br /> Job Address �2,[— <br /> Phone � t7 <br /> l/ >��dress j', <br /> X Owner's :W��rt <br /> ame <br /> !! �\ Address License No. - Phon J <br /> ContractDESTRU ❑ ;i <br /> TYPE OF L/P NSW WELL ❑ WELL REPLACEMENT ❑ <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR Q OTHER ❑ I: <br /> SEWER LINES ISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS li . <br /> FOUNDATION AGRICULTURE <br /> w <br /> INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS tvti� <br /> Dia. of Well Casing ` <br /> ❑ industrial <br /> LJ Bottom ❑ eca Dia. of Well Excavation \ <br /> Type of Casing Specifications !� <br /> I <br /> ❑ Domestic/Private ❑ Gravel Pack C1Tracy Grout Seal Type of Grout <br /> Depth ofrou <br /> ['I Public ❑ Other D Delta i. <br /> I Irrigation Approx�Depth i I Eastern Surface Seal Installed by h <br /> IH.P State Work Done <br /> Repair Work D Type of Pump <br /> Sealing Material (top 50'1 <br /> Well Destruction ❑ Well Diameter I, <br /> Depth I Filler Material (Below 501 <br /> INSTALLATION I"I REPAIRIADDITION i I DESTRUCTION I No septic system <br /> m rented if public sewer is I'' <br /> TYPE OF SEPTIC WORK: NEW a ailable w i <br /> Installation will serve: Residence Commercial, Other <br /> living units: <br /> Number of bedrooms <br /> Number of g . Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> T e/Mf Capacity <br /> SEPTIC TANK ,yP g Method of Disposal <br /> PKG, TREATMENT PLT. ❑ � Property Line <br /> Distance to nearest: Well Foundation lk <br /> Total length/size <br /> { LEACHING LINE ❑ No. & Length of lines property Line I; <br /> FILTER BED ElDistance to nearest: Well Foundation <br /> SEEPAGE PITS l I Depth Size Number <br /> Foundation Property Line <br /> SUMPS Ll Distance to nearest: Well I, <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will begone in accordance with San Joaquin county ordinances, state law;, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> ` ture certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signa <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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 applican s 11 far equir spa so s Complete drawing on reverse side. <br /> f <br /> Title: ' Date: <br /> ✓Signed I <br /> f_ FOR DEPARTMENT USE ONLY �! <br /> I Date ONO— Area (J <br /> f Application Accepted by ' <br /> Date Final Inspection by <br /> Data L ? <br /> Pit or Grout Inspection y <br /> Additional Comments: <br /> F LJStk 466-6781 ❑ Lodi 369-3621 ❑ anteca 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 /> AMOUNt D E AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> FEE ASH <br /> INFO h' <br /> + EH 132 (REV.I/K b 31< <br /> EH 1428 <br />