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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT # <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 /> l <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 welllpump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> { f� l y' City r�15ot`Siie " ar._ - `PM <br /> Job Address nn f <br /> ~ �k 1•" .liY as v ... e - l.,.. ♦P'.-.':i:! '.'-}. s. <br /> 3 `- ! ._ <br /> Owner's Namef #` V" L Address Phone <br /> - L L-Address 3��T� ��V 1O�icei seN — �149^�Phone <br /> - i <br /> �� Contractor�� '1 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT'❑ DESTRUCTION ❑ <br /> r PUMP.:INSTALLATION ❑ SYSTEM REPAIR ❑ -OTHER ❑ f <br /> DISTANCE TO NEAREST: SEPTIC ITANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE '_TYPE,OF WELT; PRO BLEM-AREA_;_CONST.RUCT-ION SPECIFICATIONS <br /> ❑ Industrial 1]-Open Bottom : ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Specifications <br /> cifications i <br /> El Domestic/Private ❑-Gravel,Pack 1 ❑ Tracy Type of Casing , Pe <br /> ❑ Public CI Other_/ ED Delta Depth of_Grout Seal j Type of Grout <br /> ❑ Irrigation i ---Approx. Depth ❑ Eastern._# =Surface Seal Installed by t <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done l <br /> Well Destruction ❑ Well',biameter f Sealing Material (top 50') <br /> e Depth' ' y Filler Material'"(Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION L--INESTRUCTION ❑ .(No septic system permitted if public sewer is p(j <br /> .available within 200 feet.) <br /> Installation will serve: Residence.',fCommercial ther <br /> a -, 1 } <br /> Number of living units:�" Number. of bedrooms f v <br /> Character of soil to a depth of 3 feet: T _ '` I`F'� _ Water table depth <br /> SEPTIC TANK ❑ Type/,Mfg I C h Capacity No. Compartments <br /> s / 3 t <br /> PKG. TREATMENT PLT. ❑ � Method of Disposal <br /> i <br /> Distance to nearest: We Foundation koperty Line <br /> I <br /> LEACHING LINE M--No. & Length'of lines —1 — -^ Total 1ength/size ` <br /> i <br /> FILTER BED ❑ Distance to nearest: Well Foundationt Property Line <br /> SEEPAGE PITS 1---Depth Size Numb <br /> SUMPS' ❑ Distance to nearest: ,-<"Well r" Foundation .�roperty Line I <br /> DISPOSAL PONDS ❑ +� ^J ` f <br /> I hereby certify that I have prepared this application and that the work will be done in accordance v,rlth San 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 certify that in the performance of the work for which this permit is issued, I shall not <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 tfiie hermit is iss—ue t sf ail employ persons subject to workman's compensa- <br /> . tion ie ' of California" <br />[ The applica st callf all re (red�.fi -plete rawing on r verse std f <br /> e ! <br /> Signe + Title: Date: <br /> `( FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Date final Inspection by Date <br /> Pit or Grout Inspection by I r <br /> Additional Comments: JQ <br />�. ❑ Stk '466-6781 ❑ Lodi 369 3621 ❑ Manteca 04 El Tracy 835-636 <br /> Applicant- Return a6 copies to: Environmental Health Permit/Services 1601"E.' Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE. f. AMOUNT REMITTED CASH RECEIVED BY DATE'. PERMIT'`N0. <br /> INFO <br /> P t , <br /> + EH 13-241REV..i/e 51 <br /> I' EH 14.26 1 <br />