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APPLICATIOWFOR PERMIT -7-4- _,45 w <br /> SAN JOAQUIN LOCAL HEALT4 61STRICT """�7��'*- , <br /> 1601 E. HAZETON AVE.,,STOCKTON,FCAW.e < <br /> "Telephone PC <br /> (2091 466-6781 ' , Mo ��" S <br /> u� ,. ., ... 't to r f <br /> PERMIT EXPIRES 1 YEAR"FROM DATE ISSUED <br /> +(Gamplete in Friplicate­Aliaj } �; •�. •.4 �•. .�. , <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 Rebulations of the San Joaquin <br /> Local Health District. <br /> t J �lfl'�-` ' ^l .rJ F r' ' , ' .' ,. . <br /> so <br /> S .S City. Lot Size/ PM <br /> Job Address _ <br /> Phone . <br /> Owner's Name ? Address <br /> -Fa ((ay�� <br /> Contractor l _� _ License No. y Phone <br /> TYPE OF WELL/PUMP: NES/V-WEL-011's�^k%�Z_VVELL REPT CEMEAfT ❑. A' DE-STRUCTION ❑ <br /> ,-- MF'INSTAL°LA710N-0` j `OTHER <br /> DISTANCE TO NEARESVJ' SEPTIC TANK . SEWER LINES; DISPOSA�FLO. LINE i <br /> FOUNDATION AGRICULTURE WELL OTHE PITS/SUMPS _ , <br /> INTENDED USE i TYPE OF WELL PROBLEM AREA CONSTRU SPECIFICATIONS <br /> ❑ Industrial j Q Open Bottom 171Manteca . of WeILExcavation Dia. of Well Casing <br /> ❑ Domestic/Private' O Gravel Pack ❑ Type of Caning Specifications <br /> S <br /> ❑ Public ❑ Other ❑ Delta Depth orG out Seal Type of Grout F <br /> ❑ Irrigation pproz. Depth ❑ Eastern Surface Seal Installed by i <br /> Repair Work Don Type of Pump H. <br /> P. State Work Done I <br /> Well Dest ion ❑ Well Diameter "� ;, Sealing Material.(top 501;f i <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑C REPAIR/ADDITIO ❑ J TRUCTIO iNo septic system permitted if public sewer is <br /> r _ F �] + av ilable within 200 f ) j. <br /> Installation will serve: Residence; Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: ° Water table depth <br /> SEPTIC TANK Type/Mfg Capacity '')No. Compartments 4 <br /> PKG. TREATMENT3PLT. 0Method of Disposal I <br /> ;r Distance to nearest: Well i^ Foundation' Property Line <br /> � � r <br /> LEACHING LINE ❑ No. & Length'of lihes Total length/size I <br /> FILTER BED ❑ Distance t. neare ;____weL_...._.._...'Foundation-n•J Property Line <br /> f,. « � i 3 <br /> SEEPAGE'PITS ❑' Depth Size Number <br /> SUMPS ❑ Distance`fo nearest: Well Foundation Property Line £ <br /> 6ISPOSAL PONDS I _J " <br /> I hereby certify that_I have prepared-this application and that the work will'be done in accordance with San Joaquinycounty ordinances, state laws, and <br /> rules and regulations of the San J6aquin 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 perfdrmah6e of the work for which this permit is issued, I shall employ persons subject to workman's'compensa- <br /> tion laws of California." r 1 <br /> The applicant ust call for required 'nspections. Complete drawing on reverse side. <br /> ` 8 <br /> Signed If <br /> Title: r Date: <br /> FOR DEPARTMENT USE ONLY ]/ <br /> Application Accepted by <br /> Date Area t <br /> Pit or Grout Inspectipn Date Final Inspection by Date } <br /> Additional Comment;: <br /> i ❑ Stk 466-6781 ❑ Lodi 369 3621 ❑ Manteca 623-7104 _ ❑ Tracy 835 6385 a [� <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.; CA 952011 r <br /> FEE AMOUNT DUE AMOUNT REMITTED SCK �} RECEIVED BY DATE PERMIT�NO. <br /> INFO CASH <br /> + EH13-241REV,i F,51 <br /> EH 14-28 '- <br />