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�,. APPLICATION FOR PERMIT ,.. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT '� i { <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA k <br /> Telephone (209) 466-6781 APR 9 1S'27 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH <br /> (Complete in Triplicate) PERM IT/SEW ICES <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 /> ILocal Health District, <br /> Job Address Cit l t Size PM <br /> O 's Name Alex Address ��!�ei Phone qg`—0 0 � <br /> w erjr 3 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ f WELL REPLACEMENT ❑ [ DESTRUCTION ❑ i <br /> PUMP INSTALLATION' SYSTEM REPAIR ❑ OTHER ❑ � <br /> I <br /> DISTANCE TO NEAREST: SEPTIC'TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDA-TION .: - AGRICULTURE WELL OTHER WELL PITS/SUMPS i <br /> INTENDED USE TYPE OF WELLRP OBLEM AREA CONSTRUCTION SPECIFICATIONS I <br /> D Industrial —B-Open-Bottom- --FI-Manteca s- Dia: of Well-Excavation— a Dia. of Well Casing i <br /> omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public D Other D Delta Depth of Grout Seal ! Type of Grout_ <br /> ! Irrigation _..Approxi Dep[ stern . -Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump tl H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'I <br /> Depth Filler Material (Below 50') r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I-) REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet) +M1 <br /> Installation will serve: ResidenceCommercial_ Other x+111 <br /> Number of living units: Number of bedrooms ; <br /> Character of soil to a depth of 3 feet: I Water table depth <br /> SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ .`Method of Disposal <br /> �1 <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 1-:] No. & Length of lines Total lerigth%size <br />'I Property Line <br /> FILTER BED ❑ Distance to nearest: Well Foundation �t <br /> I A` <br /> SEEPAGE PITS I Depth I Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> �. <br /> DISPOSAL""PONDS­`" _❑� ""�` �� <br /> II I hereby certify that I have prepared this application and that the work will be done in accordance with 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 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." <br /> 4 <br /> The applicant st call or II required inspections. Complete drawing on rev tse side. <br /> Signed �� Title- Date: o <br /> i OR DEPARTMENT USE ONL <br /> r <br /> Application Accepted by Date f` Area <br /> Pit or Grout Inspection by Date Final Inspection by _ _ Date <br /> t <br /> Additional Comments: <br /> i D Stk 466-6781 D Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Enviro{ental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE ' AMOUNT REMITTEDCASH RECEIVED BY DATE PERMIT'NO, <br /> INFO <br /> I +.EH 13.24 1REV.I/H 51 <br /> EH 14-26 <br /> I <br /> k <br />