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Y <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �l <br /> 1601 E. HAZE I ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 JAN <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> I <br /> ean <br /> � <br /> (Complete in Triplicate? Ey�;ROi�MENtAV,��SL <br /> g-R%l�i SRR t <br /> Application is hereby mahe San(Joaquin local Health District for a permit to construct and/or install the work h�r n +s application is <br /> made in compliance withoaquin 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. �i # <br /> 1 City f Lot Size M <br /> Job Address 3. <br /> + <br /> ' ddress �~ Phone <br /> Owner's Nam <br /> icense No Phone <br /> Contractor Address - <br /> TYPE OF WELLIP P: NEW LL ❑ WELL REPLACEMENT 0 RUCTION N'� <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ �r THE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public I n Other Ll Delta Depth of Grout Seal _IQ + Type of Grout_dla <br /> I I Irrigation Approx, Depth I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump jr— H.P. tate Work Done <br /> Well Destruction y Well Diameter Sealing Material Stop 50'I - <br /> Depth �� f - Filler Material (Below 50'} <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is , <br /> #i available within 200 feet.) <br /> installation will serve: Residence— Commercial Other <br /> Number of living units: N}mber of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type Mfg Capacity No. Compartments , <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> r . <br /> i <br /> LEACHING LINE ❑ No. 811_ength of lines Total length/size <br /> r <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS ❑ Distar ice to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ r <br /> I hereby certify that I'have prepared-this application and that the work will be done in acc6rdance`with San Joaquin county ordinances;state laws;a'rid'~ <br /> rules and regulations of the San Joaquin Local Health District. <br /> rtify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I ce <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." j <br /> The applicant mu II for all r -inspectio ete drawing on reverse side. <br /> Signed X tile: Date: .' - <br /> `t <br /> FOR DEPARTMENT USE ONLY f <br /> )::�v <br /> Date J Area . <br /> Application Accepted by <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: - <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 6385 <br /> Applicant - Return all copies to: Erivironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> AMOUNT D UE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> FEE GASH y— `r <br /> INFO q <br /> r.EH 13-2.1(REV.!/H 5) <br /> EH 14-26 <br />