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APPLICATION FOR PERMIT $ CIC rr Q <br /> { SAN JOAQUIN LOCAL HEALTH DISTRICT '- 5 <br /> 1601 E. HAZELTON AVE., STOCKTON, CA ` <br /> Telephone (209) 466-6781 <br /> r 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 desc <br /> made in compliance with.San Joaquin county Ordinance Noribed. This application is <br /> _ .549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> r <br /> Job Address <br /> ra+� <br /> City Lot Size , /0 S PM <br /> Owner's Name �• �� <br /> 1. ,Add ,( t7 <br /> . ._ — Phone <br /> Contractor ` Address Y <br /> ' Phone <br /> TYPE OF WELL/PUMP: '`" NEW'WELL' '0-" - `^`—='yyELLREPL`ACEMENI LA DESTRUCTION ❑ r <br /> �.� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ _J )OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDISPOSAL FLD. PROP. LINE <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> _ INTENDED USE i TYPE OF WELL_PROBLEM.AREA_CONSTRUC.T.ION,SPECIFICATIONS f <br /> ❑ Industria! 1 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> ❑ Domestic/Private j El Gravel Pack 11 Tracy Type of Casing ( t S ' <br /> pecifications <br /> fl;Public <br /> ❑ Other" C] Delta Depth of Grout Seal Type of Grout <br /> �❑ Irrigation ---Approx.:Depth ❑ Eastern Surface Seal Installed by I <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') s <br /> Jali <br /> DePih ° 1 Filler Material (Below 50'I O <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REP R/ADDITION ❑ DEST CTION ❑ (Na septic system permitted if public sewer is <br /> r f �� available within 200 feet.) . <br /> Installation will serve: Residence{ Commercial_ 'Ot ��- <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet s <br /> Water table depth <br /> SEPTIC TANK 1 ❑ Type/Mfg Capacity No. Compartments r <br /> PKC. TREATMENT PLT. E3 Method of Disposal <br /> Distant e to nearest: Well Foundation <br /> � Property Line � <br /> LEACHING LINE r ❑' No. & Length of lines �' Total length/siie l <br /> FILTERBED�" ❑ Distanceto nearest:—Well---__,.�Foundation� Prope �� <br /> rty`Line <br /> S <br /> SEEPAGE PITS c ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISP.OSgL'PONDS ❑ " <br /> L <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�Local-Health District!- <br /> re <br /> Home owner or licensed agent's signatucertifies 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."Contractar'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 <br /> tion laws of California." t rp Y persons subject to workman's compensa- <br /> tion <br /> applican must call for all required inspections. Complete drawing on reverse side. e <br /> Signed Title: r <br /> Date: <br /> EPARTMENT USE ONLY - <br /> Application Accepted by 0►ti: f �, <br /> Date i \3 0 d <br /> Area <br /> Pit or Grout inspection by Date Final Inspection by Date <br /> Additional Comment's <br /> i ❑ Stk 466-67810 Lodi 369-3621 ElManteca 823-7104 CJTracy 835-6385 2 <br /> f Applicant- Return all c%opies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEDCK <br /> INFO CASH RECEIVED BY DATE EPERMIT'NO.+ EH 14-24 1AEV.t/B 5! �a ��8 �EH 14-28 <br />