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I! APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL TON AVE., STOCKTON, CA ` <br /> it Telephone'(209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED, <br /> (Complete in T�riplicate) <br /> -- <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 I <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the RgIes and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address `'�I / r City _ Lot Size PM <br /> Owner's Name Address l,�� � :_�tf 6r� Phone t <br /> Contractor A dress r r License N Phone <br /> TYPE OF WELL/PUMP': NEW WELL ❑ WELL REP AGEMENT,❑ DESTRUCTION ❑ I <br /> II PUMP INSTAiLATION ❑� SYSTEM REPAIR❑ OTHER ❑ r _ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> Ir FOUNDATIONAGRICULTURE WELLOTHER WELL PITS/SUMPS <br /> INTENDED USE I TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca �. Dia. of Well Excavation� Dia. of Well Casing <br /> Ll Domestic/Private I LJGravel Pack IDTracy T Type of Casing Specifications <br /> ❑ Public I ❑ Other ; ❑ Delta _ Depth of Grout Seal Type of Grout <br /> ❑ Irrigation II --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump ' H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material (top 501 I n <br /> II Depth Filler Material (Below 501- <br /> TYPE OF SEPTIC WORK: NEW INSTALLAyTIO REPAIR/ADDITIONDESTRUCTION (No septic system permitted if public sewer is <br /> t r// .� available within 200 feet.) <br /> Installation will serve): Resi ence_ Commercial_ Other <br /> Number of living units: � NumbAR5�� <br /> -_ '".�_. .- <br /> Character of soil to a depth of 3 feet{ ( Water tabledepth 7 <br /> SEPTIC TANK II X Type/Mfg Capacity__17_x— No. CompartmentsJ'AG. TREATMENT PLT. ❑ a." zf �f�qr, r�.. #fir,; �" ; Method of Disposal ! I <br /> I� Distance to nearest: Well�f�1_' Foundation _ e— Property Line <br /> `LEACHING LINE Ij ❑ No. & Length of lines._ : 1 :! '= t r ;Total length/size <br /> FILTER BED Distance to nearest: 1Nell--tom/� poundation f/ Property Line 9 <br /> SEEPAGE PITS ❑ Depth Number <br /> SUMPS I; ❑ Distance to nearest: Well t w Foundation Property Line �. <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that l have prepared this application and that the'work-Wilt be�dorie in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local.-Health District.. 'r <br /> r <br /> Home owner or licensed agent's signaturwcertifies the following: I certify.thdt.in the performance�- <br /> of a work for which this permit is issued, I shall not <br /> efnploy any person in such manner as to became subject!to wo[kman's compensation laws-of-Gallfornia.--_Contractor's hiring or sub-contracting signature <br /> certifies the following::;'l certify that in the performance of the work forwriicFi this`P&Tjj is-sued; I-shall employ persons subject to workman's compensa- <br /> tion laws of California:" j l r <br /> The applicant muW call for all r uired 'Umpections. Complete drawing on reverse side. <br /> "Signed41`Title: Date: 1QJZ <br /> II <br /> 4FOR DEPARTMENT USE ONLY <br /> Application Accepted Iby <br /> n `� 1` Date a`. 0 Area <br /> II 4, <br /> r Data <br /> Pit or Grout Inspection by Date Final;Inspection by <br /> Additional Comments; , <br /> ❑ Stk 466-6781 ❑ Codi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385'. <br /> I'Applicant- Return all'Icopies to: Environmental Health Permit/Services 1601 E. Hazelton Ave`., P.O. Box 2009,-SW.'CA 95201 <br /> IFEE <br /> NFO °I AMOUNT DUE AMOUNT REMITTED CASH `RECEIVED BY_'' BATE. P£RMIT'NO. <br /> +EH 1324[REV.1/B 5) �4 .}-1 .. ► T�;q- ..., '�*s+ `0 �/ .�12 <br /> EH 14-26 <br />