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-� APPLICATION FOR PERMIT s (� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE"'TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _ <br /> (Complete in Triplicate) F <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 /> - <br /> Local Health District. <br /> Job Address E Cit .e1 <br /> x Y Lot Size 5'401S`o <br /> PM <br /> r <br /> Owner's Name — <br /> Phone - Z <br /> Contractor E,J&Agy jo Address4r Lar t.t�� <br /> License IVo. �-7� Phone '397 I <br /> TYPE OF WELL/PUMP: iNEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industria! ❑ Open Bottom ❑-Manteca Dia. of Well Excavation <br /> ❑ Domestic/Priv ate El Gravel Pack Dia- of Well Casing <br /> E2Public Cl Tracy Type of Casing r Specifications <br /> ❑ Other ❑"Delta Depth of Grout Sea! <br /> 11 Irrigation Type of Grout <br /> --Approx. ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump y p <br /> State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material ltop 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 204 feet.) <br /> Installation will serve: Residence�" Commercial �4ther w <br /> Number.of living;units: Number of bedrooms f ! I <br /> Character of soil to a depth of"3rfeet: <br /> SEPTIC TANK Water table depth <br /> Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well ' Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> I r ` ! Total length/size <br /> FILTER BED ❑" Distance to nearest: Well Foundation <br /> Property Line , <br /> SEEPAGE PITS Depth 1 - Size <br /> SUMPSNumber <br /> ❑ . Qistance to nearest: Well �� '''"'tFoundation <br /> DISPOSAL PONDS ❑ ' ' Property Line <br /> r- n <br /> l hereby certify that I have prepared this application and that the w6r0wiil 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 foliowing: "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 /> The applicant must call for all requiredLinspectio Complete drawing on reverse side. <br /> Signed X Title: <br /> • bate: "" 3C7 J7 7 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by a � Ab <br /> � �fz <br /> I Area <br /> Pit or Grout Inspection b Date Final Inspectio ��-�--- cF 2 r <br /> Date <br /> Additional Comments: - <br /> ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7144' ❑ Tracy 835-5385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> r t <br /> r <br /> [FEE AMOUNT DUE �- ^-^AMOUNT REMITTED-y- — <br /> INFO CASH — "`--"RECEIVED BY DATE PERMIT N0, <br /> + EH M24(REV.1.1 n s) <br /> EH 14-28 i t— = 2 ` --5o Cn "1 —)V <br />