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t <br /> APPLICATION FOR PERMIT <br /> SAN JrQUI'I LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> ii : <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. 1882 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. f <br /> ��7 city t�Lot Size ` PMJob Address 14 TJ 4 <br /> I Address a y -�� �K— Phone 1 <br /> Owner's Name ,! J� <br /> Contractor <br /> wg y Address,? License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ <br /> I <br /> PUMP INSTALLATION CSYSTEM REP ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER ES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTU WE OTHER WELL PITS/SUMPS <br /> 1 INTENDED USE TYPE OF WELL PROBLEM AREA CO UCTION SPECIFICATIONS <br /> I <br /> ❑ Industrial ❑jOpen Bottom 1:1 Manteca ra. of W Excavation Dia. of Well Casing <br /> Type of Casio <br /> ClPGType of Grout Specifications <br /> ❑J - { <br /> ❑ Domestic/Private ravet Pack ❑ Tracy <br /> M Public ,Other Ll Delta Depth of Grout al <br /> i I i Irrigation _-Approx. Depth l 1 Easte Surface Seal Install by Q <br /> Repair Work Done [2 Type of Pump H.P. <br /> ate Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION i I DESTRUCTION I i avtailabpticle system <br /> m rented if public sewer is <br /> Installation will serve: Residence*Z Commercial— Other \ <br /> Number of living units: Number of bedrooms (� <br /> Water table depth <br /> Character of soil to a depth o1 3 feet: ?-� <br /> Capacity Q100 No. Compartments 01 <br /> SEPTIC TANK Type/Mfg <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑iI <br /> ! Distance to nearest: Well Foundation 3 Property.Line <br /> i!I <br /> LEACHING LINE No. & Length of lines a S Total length/size <br /> i <br /> FILTER BED ❑I Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth 1 _ SizeNumber <br /> i <br /> SUMPS LT Distance to nearest: Well 11�0 Foundation 110 0 Property Line 2� <br /> t SPOSAL PONDS ❑I <br /> 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 D%trict. <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 /> p 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." Ij <br /> The applicant must II for' r quired inspections. Complete drawing on reverse side. n <br /> 1 �j Signed X Title: Date: c7 <br /> FOWIREPARTMENT USE ONLY ] <br /> l Application Accepted by �r Date V`a�^�! Area <br /> Pit or Grout Inspection by, <br /> Date Final inspection byll Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑'Lodi 369-3621 ❑ Manteca 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 /> q <br /> FEEMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. <br /> INFO <br /> +.EH 13-24[REV.1/H5) �a [OV / r. 10D " C AI;// <br /> EH 14-2e , <br />