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APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZE T ON AVE., STOCKTON, CA <br />Telephone (209) 466-6781 <br />PERMIT EXPIRES TYEAR 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. 18112 for well/pump and the Rules and Regulations of the San Joaquin <br />Local Health District. }./ <br />Job Address 16 'ot si� Vie" l R e" o �6 U • City7r_�I&l Lot Size PM <br />r. <br />Owner's Name �Pou �5 Address 2� hL Phone <br />Contractor r /t. Address DTA S Lice�o 1337 '3 Phhon- <br />TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br />PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br />a <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />❑ Industrial <br />❑ Domestic/ Private <br />FI Public <br />I i Irrigation - <br />Repair Work Done ❑ <br />Well Destruction X <br />❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br />❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br />* Other 1 171 Delta Depth of Grout Seal Type of Grout <br />—_Approxi Depth l I Eastern Surface Seal Installed by <br />t <br />Type of Pump H. P. / State Work Done _ <br />Well Diameter a2 Sealing Material (top 501 Lal 0zC_ <br />Depth X42 —2 t Filler Material (Below 50') <br />TYPE OF SEPTIC WORK: <br />NEW INSTALLATION l I <br />Installation will serve: <br />Residence Commercial <br />Number of living units: <br />Number of bedroom; <br />Character of soil to a depth <br />of 3 feet <br />SEPTIC TANK <br />❑ Type/Mfg <br />PKG. TREATMENT PLT. <br />❑ <br />Distance to nearest: <br />I <br />LEACHING LINE <br />❑ No. & Length of lines <br />FILTER BED <br />3 <br />❑ Distance to _nearest: <br />I <br />SEEPAGE PITS <br />{ I Depth I <br />SUMPS <br />❑ Distance to nearest: <br />DISPOSAL PONDS <br />Cl I <br />REPAIR/ADDITION I I D <br />Other <br />(No septic system permitted if public sewer is <br />available within 200 feet.) <br />Water table depth- <br />Capacity <br />epth_Capacity No. Compartments <br />Well Foundation <br />Well Foundation <br />Size <br />Well Foundation <br />Method of Disposal <br />Property Line <br />Total length/size_ <br />Property Line <br />Number <br />Property Line <br />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 16 become subject to workman's compensation taws of California." Contractor's hiring or sub -contracting signature <br />certifies the following: "I certifythe in the performance of the work for which this permit is issued, i shall employ persons subject to workman's compensa- <br />tion laws nia.' <br />The applicant m all all r quired inspections. Complete drawing on re rse siop. <br />Signed XTitle: 4(V1 -f Date: <br />FQR EPARTMENT USE ONLY <br />Application Accepted by Date C . Area <br />Pit or Grout Inspection by Date . Final Inspection by Date%D 2(h d� <br />Additional Comments: - )1 <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 85201 <br />+ EH 13-24 IREV. 1/ a 51 <br />- FH 14-2a <br />FEE <br />INFO <br />AMOUNT DUE <br />AMOUNT REMITTED <br />I RECEIVED BY <br />DATE <br />PERMIT NO. <br />I <br />I� <br />kA <br />1 <br />C <br />