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1 > APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 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 withSanJoaquin 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 /> ' { <br /> Job Address q2 6 ��(;(� ����Q�� � (��� /v� <br /> e City Lot Size ! PM <br /> r ;. <br /> Owner's Name Address-A� 'Jr Phone �K� 2_� <br /> �.. ' Aa&"Contractor dress t <br /> License No. V Phone? -�1 <br /> TYPE OF WELL/PUMP: f NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP_INS.T.ALLATION,-❑ SYSTEM"REPAIR"Q OTHER-0- <br /> -DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL\`FLb. 3 PROP. LINE <br /> t ,«• <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' t <br /> ❑16clustrial ❑ Open Bottom ❑ Manteca Dia:of Well Excavationj <br /> bio. of Well Casing I <br /> ❑Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> rout jSpecifications❑ Public ❑ Other -Depth-of Type <br /> Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern 41Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump ? W.P `� State Work Dane ' <br /> Well Destruction P.❑ Wel! Diameter Sealing Material (top 50') 1 <br /> i <br /> i Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/NDIT12fl ❑ DEST CTION)L] (No septic system permitted if public sewer is <br /> d # available within-200 feet.) <br /> Installation will serve: Residence Commercial O er �'may{, <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: [ � .J f <br /> SEPTIC TANK ❑ Type/Mfg{ s r," '" Water table depth <br /> ,,; <br /> Capacity S No. Compartments <br /> PKG. TREATMENT PLT. ❑ - ✓�:� +�, <br /> s _k�_J t '1 _ ��w Method,of Disposal <br /> Distance to nearest: Well Foundation r•. / .-i <br /> Property_0r-" 1 4 <br /> LEACHING LINES . "❑""'No...& Lendth":of lines f i <br /> Total length/size <br /> FILTER BED ❑ Distance to.nearest: Well Foundation Property Line ) <br /> SEEPAGE PITS ❑" Depth Size Number r <br /> SUMPS ❑ Distance to',nearest: Well Foundation P <br /> DISPOSAL PONDS ❑ <br /> r roperty Line <br /> � <br /> 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 L_ocal Health District. <br /> Home owner or licensed agent's signature certifies the followin +"�" -"�'---I' <br /> employ an g= ' certify that in the performance of the work for which this permit is issued, I shall not <br /> P y y 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 ust call fo�equirBd�nspections. Complete drawing on reverse side. <br /> i r F <br /> Signed 1 Title: <br /> p Date: <br /> 1 FOR DEPARTMENT.-USE ONLY ' <br /> Application Accepted.by i Z <br /> y ` �• ` Date Area <br /> F � i <br /> Pit or Grout Inspection Date " Final Inspection byjj� <br /> Date <br /> Additional Comments <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 1 ❑ Manteca 823-7104 -0 Tracy 835-ti385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazekon Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEDCK <br /> INFO CASH RECEIVED BY DATE PERMIT NO. <br /> + EH 1324(REV.1/as) <br /> EH 14-28 <br />