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APPLICATION FOR PERMIT L" <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 /> 4 (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. ry ; <br /> Job Address j 5]j 5 -6 ` 7� S+ City Lot Size PM <br /> Boil <br /> j j ../?0-ISTD 14,6 I <br /> Owner's Nam Q✓I i� �bibles Address J�r� � ��� Phone <br /> p' <br /> Contractor p CtICL, Address al 11 License No.�K .Phone P �6 <br /> TYPE OF WELL/PUMP: , NEW WELL ❑. WEIF REPLACEMENT ❑ DESTRUCTION Q <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED_USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ industrial M Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy - Type of Casing Specifications <br /> f-I Public C1 Other ❑ Delta Depth of Grout Seal Type of Grout _. <br /> I I Irrigation _Approx. Depth l i Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ <br /> Well Destruction ©—WelLAiameter Sea g Material (top 50') <br /> Depth Filler Material (Below 50'J <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION l l REPAIR/ADDITION'1'91-�EST#i TION)CI (No septic system permitted if public sewer is ` <br /> available within 200 feet.l <br /> Installation will serve: Residence Commercial_ Other ��`' 1✓ <br /> _ Number of living units: Number of bedrooms VA <br /> Character of soil to a depth'of 3 feet: Water table depth <br /> " SEPTIC TANK Type/MfgCapacity No. Compartments <br /> I -�t <br /> PKG..TREATMENT PLT. _ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines d Total length/size <br /> FILTER BED © Distance to nearest: Well 1 Foundation Property Line <br /> t <br /> SEEPAGE PITS l I Depth kite Number. <br /> SUMPS ❑ Distance to nearest: lWell Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> hereby certify that I have prepared this'application and that the work will be done n accofdarice with San Joaquin county ordinances, state laws, and { <br /> rules and regulations of the San Joaquin Local Health District.wi __ <br /> Home owner or licensed agent's signature certifies the follong: l certlfy`tttat4n.th 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."Contractors 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 arsons subject to workman's compensa- <br /> tion <br /> � Y Pe P P Y R I P <br /> tion laws of alifornia." f <br /> The appIP4rn all for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: L� 1 Date: <br /> r FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date b 3Area �I <br /> Pit or Grout Inspection by Date Final Inspection by / Date <br /> Additional Comments: C'} <br /> ❑ Stk 466-6781 © Lodi 369-3621 ❑ Manteca -7104 CI Tracy 835-6385(0 <br /> Applicant - Return all copies to: Environmental Health Permit/Service 1601�E. ,H6z�elton AvkL,; P.O. Box 2009, Stk., CA 95201 <br /> t <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED C K H RECEIVED BY DATE PERMIT'NO. <br /> + EH 1344{REV-1/n 51 <br /> EH 14-28 <br />