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.t,APPLiCATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT Zo •�• <br /> !� 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> 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. <br /> Job Address City Lot Size�� X PM <br /> Owner's Name Address Phone <br /> Contractor 4 . dd ss _`_ License.No.n on.Phone—902- <br /> TYPE OF WELL/PUMP: or NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ `1 SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK EWER ER LINES ISP SAL FLD. PROP. LINE <br /> I FOUNDATION A ICULTURE WE OTHER WELL PITS/SUMPS: <br /> INTENDED USE TYPE OF WELL AnS <br /> STRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack\ e of Casing Ir y Specifications <br /> ❑ Public ❑ Other 1 ' th of Grout Seal ~ Type of Grout <br /> ❑ Irrigation �Approx. Depthce Seal Installed byRepairWork Done Type of Pump State Work Done I <br /> Well Destruction Well Diameter Sealing Material It I <br /> Depth Filler Material (Below 50 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAtRLAPPITUAL0 DESTRUC 1ON ❑ o septic system!permitted if public sewer is <br /> _allable within 200 feet.} f' <br /> Installation will serve:'�Residence Commercial""` ther+ '�.�. <br /> Number of living units: Number of bedrooms.� ti l (-A <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nea4 Well Found t' Property LineCy <br /> i <br /> .7 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: ell F ndation Property Line I <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line fAk1` <br /> DISPOSAL PONDS F-1 ../\�J.. <br /> I herebly certify that I have prepared this application and /ework <br /> ork wi a done in accordance with San Joaquin county ordinanc4s, state laws, and <br /> rules and regulations of the San Joaquin Local Health Di <br /> Home owner or licensed agent's signature certifies the folcertify that in the performance of the work for which this pert-l issued, I shall not <br /> employ any person in such manner as to become subject n's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance offor which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws-of California."The applica ust all f2!,01 require inspections. Complete drawing on reverse side. �1 <br /> Signed ^ Title: 0-t41�L9,� Date: 'Z u <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Dat r e7 Area <br /> Pit or Grout Inspection by Date Final Inspection by HXA fL Date <br /> Additional Comments: AN � U--I'-` T!7e <br /> ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 8.354KM <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT N0. <br /> + EH1&24(REV.I/e 5) ��+ <br /> EH 1428 � -�J <br />