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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 'I 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 CountyOrdinanceNo. 549 for sewage or No. 1862 for well/pump and the Rules and Regula io sZf he n aquin <br /> Local Health District. <br /> uF <br /> Job Address O� c Cit ��/�'5 <br /> &!10-� y - �� Lot Size �. PM <br /> a.Owner's.Name__�s- _ 4t�f i'0_ Address v cehff, Phone Contractor � �.f- Address 4 LaQ <br /> License No. �.�.�C�- Phone <br /> ..e TYPE--OF.WELL/PUMP:— .._„_NEW-WELL-F] y. �� . WELL AEPLACEMENT_❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR El :'” \;OTHER ❑ <br /> c DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD..._-� .PROP. LINE <br /> � V <br /> FOUNDATION AGRICULTURE WELL'` ''°} OTIiER:W.,Ell �� SPITS/SUMPS _ <br /> INTENDED <br /> USETYPE OF WELL PROBLEM AREA, CONSTRUCTION"SPECIFICATIONS N,a <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Q Domestic/Private ❑.Gravel Pack ❑ Tracy Type of Casing <br /> I Specifications r <br /> F] Public Ll Other ❑ Delta Depth of Grout Seal - Type of Grout <br />` I I Irrigation _._App x pepth I I Eastern 'p 5urfa e Sedl installed 6.A­ <br /> y-" " , <br /> Repair Work Done ❑ Type of Pump H.P. ,. State Work Done_ <br /> Well Destruction nn ❑ Well Diameter Sealing Material (top 501 <br />' I Depth Filler Material (Below 501 <br /> l TYPE OF SEPTIC WORK: NEW INSTALLATION I I` REPAIR/ADDITION DESTRUCTION E I (No septic stem permitted if <br /> I j P Y p public sewer is <br /> available within 200 feet.) t <br /> r 1, Installation will serve: Residence " 5""'Coriimarcial' OtFier <br /> i -•-�4 � + <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:I a ✓. /' Water table depth <br /> SEPTIC TANK �` CT Type/Mfg) Capacity No. Compartments I <br /> PKG, TREATMENT PLT.'❑.n, `. <br /> Method of Disposal <br /> y <br /> Distance to nearest: .. Well (Foundation _ Property Line I <br />! LEACHING LINE No. & Length of lines _i 5 V 14 <br /> Total length/size <br /> 4 FILTER BED Distance td'fnearest: .a Well_ID I�_ Foundation s� <br /> 3 � £� � Property Line <br /> f <br /> i SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well "n' Foundation Property Line <br /> DISPOSAL PONDS . ❑ <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 /> l rules and regulations of the San Joaquin 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 shalt 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 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 /> r <br /> The applicant must call forrall_required inspections. Complete drawing on a arse side. a <br /> Signed X / -'Title: <br /> 1 Date: <br /> t R D ARTMENT USE ONLY <br /> E �f t <br /> 1,Application Accepted by rDate Arear <br /> j <br /> Pit or Grout Inspection by Data Final Inspection by pate '^3 <br /> 1 Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 171 Manteca 823-7104 ❑ Tracy 835-6385 r <br /> d 'Applicant' Return all copies to:"Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2409, Stk., CA 95201 <br /> FEE{ INFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BY W DATE PERMIT'NO. <br /> + EH13-24IpEV.r/x51 7t�/ � �" 2�J <br /> EH 14-26 <br />