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APPLICATION FOR PERMIT ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT i+ <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 7 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.1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. FREE e <br /> 7 Q V/_ 922 � City �f Lot Size PM <br /> Job Address 5 r <br /> Owner's Name Address <br /> Phone <br /> -1 , Address �� I` License No.' 82�Phone <br /> Contractor <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT [71 DESTRUCTION ❑ <br /> PUMP INSTALLATION X RZPrCfJL��TEM REPAIR ❑ OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. " PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK \ i OTHER WELL PITS/SUMPS <br /> FOUNDATION' AGRICULTURE WELL <br /> INTENDED USE a TYPE OF WEL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Oen B' ttom t ❑ Manteca Dial of Well Excavation <br /> Dia. of Well Casing <br /> open i R. ns <br /> ❑ r Specifications <br /> ° Type of Casing Spe <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Grout <br /> D Public ❑ Other ❑ Delta Depth of Groutjj,,Seal <br /> ❑ Irrigation --!Approx. Depth ❑ Eastern Surface Seal IrSsialled by 102MAL f�,Oe- <br /> Repair Work Done ❑ Type of Pump <br /> H p I State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'i <br /> Depth Filler Materiall;(Below 501, - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION LJREPAIR/ADDITION LlDESTRUCTION 17 (No sbptiwsh n m rmiitted if public sewer is <br /> avaInstallation will serve: Residence Commercial_ Other ' <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: <br /> Capacity 4 , No. Compartments <br /> SEPTIC TANK E3Type/Mfg / .y,- Method of Disposal <br /> PKG,,TREATMENT PLT. ❑ <br /> Property Line <br /> Distance ro7 nearesf:,: Well Foundation C <br /> LEACHINO-UNE ❑ No. & Length of Hines-i } rTotal length/size <br /> ,.:, Property Line <br /> FILTER HE1]'. ` t ❑ Distance to'nearest: Well Foundation <br /> 't <br /> s 'rNornber _ <br /> SEEPAGE PITS ❑ Depth, f Size <br /> SUMPS ' Foundation Property Line <br /> ❑ Distant-6 to nearest: Well , <br /> ? <br /> DISPOSAL-PONDS ❑ lW " � _ <br /> I hereby certify that I have prepared this application-and that the-work will be done in,apcordance with San-Joaquin county-o�dinances,..state laws,-and <br /> rules and regulations of the San Joaquin Local Health\&&situ �.�tify iA <br /> Home owner or licensed agent's signature certifies the following: "I certhat 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 ofXC'Aforn'ia."Contractor's hiring or sub-contracting signature <br /> certifies the following: '9 certify that in the performance of the work for which this permit is;ssued,1 shall employ persons subject to workman's compensa- <br /> tion laws of California.' ` 1i t� <br /> I The applicant f all requi s ctions. Complete drawing on reverse e• 14 1 <br /> Date:,. <br /> Signed X —� Title:'///�� <br /> OR DEPARTMENT USE ONLY 1 <br /> 1 [ <br /> Date 7 Area—i - <br /> Application Accepted by f <br /> l Pit or Grout Inspection by <br /> Date Final Inspection by Date <br /> {' Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy" 835.6385 <br /> Applicant- Return all copie§'to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O:"Box 2009, Stk., CA 95201 <br /> FEECK# I RECEIVED BY DATE PERMIT�NO. <br /> INFO <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> + EH1S <br /> 3-24[REV.1/e 51 C <br /> I EH 14-28 _ f <br />