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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 NvU/b <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED / <br /> (Complete in Triplicate) �rT ;S 1� ��•C.�C P�� /plb *Ykt,-\ , <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 A96 <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 /> Local Health District. <br /> Job Addres �- , . F�O urLJ` City Lot Size" <br /> ize PM. <br /> {' Owner's Nama - I Address p�__. /� � e S `kc�!-X-X' Phone <br /> Contractor �' Address � d a �! icense No. Phone/` IZZ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM-REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES f ! DISPOS PROP. LINE <br /> FOUNDATION AGRICULTURE WELL THER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM ARE STR06 10N`SPECIFICATIONS g, <br /> ❑ Industrial LJ Open Bottom ❑ ca Dia. of Well Excavation Dia. of Well Casing �t <br /> Type of Casin Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack LJ Tracy g p <br /> ❑ Public ❑ Oth rt' ❑ Delta '- 'Depth of Grout1SealT Type of Grout <br /> ❑ Irrigation �Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Do Type of Pump H. State Done <br /> I Well Dest ion ❑ Well Diameter Seli <br /> ng Material Itop 50'1 <br /> Depth Filler Material IBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITiON ❑ DESTRUCTION €(No septic system permitted if public sewef 1s':. <br /> c. available within 200 feet.) <br /> Installation will serve. Residence_ Commercial_ Other Q <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth'! <br /> k SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT_ ❑ Method of Disposal C <br /> Distance to nearest: Well '""'"'-rFoundation""""""'"'""—Property Line <br /> LEACHING LINE ❑ No. & Length of lines " d _ zTotal length/size <br /> FILTER BED ❑ Distance to nearest (Well ° Foundation' 3 Property tine <br /> SEEPAGE PITS ❑ Depth t Size Number t, _ <br />' SUMPS ❑ . Distance to nearest: --t Well-- Foundation .Property Line <br />' DISPOSAL PONDS ❑ y <br /> 3 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 /> t tion laws of California." <br /> y F ' <br /> r <br /> cant mut call for all required inspections. Complete drawing an reverse side. <br /> � Signed_X Title: Q Date: - <br /> i A DEPARTMENT USE ONLY <br /> Application Accepted by Date �'1� ` Area� - <br /> Pit or Grout Inspection Date Final,I nspection by ra Date -` �� <br /> 4 Additional Comments: <br /> ❑ Stk 466-6781 171 Lodi 369-3621 ❑ M t 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 f <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED­BY'- DATE PERMIT'NO. <br /> ` INFO r� CASH <br /> V <br /> } + EH 13-24(REV.s i k s; - ,0 <br /> EH 14-28 ' <br />