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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 601 E. HAZE t ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE.ISSUED <br /> ., (Complete in Triplicate) , <br /> R <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 Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address fi <br /> City Lot Size PM <br /> Owner's Name 1r tr ,f f A <br /> Address Y + <br /> rrt tl .; -V Phone <br /> Contractor � ? � 4� � I <br /> Address j <br /> TYPE OF WELL/PUM License No. phone_ r1 <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I <br /> PUMP INSTALLATION SYSTEM REP ❑ J <br /> DISTANCE TO NEAREST: SEPTIC T _ �' OTHER ❑ <br /> SEWER LINES—.* DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTU ELL <br /> OTHER WELL f PITS/SUMPS <br /> INTENDED USE TYPE OF WELL OBLEM A <br /> Ll Industrial ❑'OCONSTRUCTION SPECIFICATIONS <br /> pen Bottom ❑ <br /> -°�- f <br /> a Dia'of Well Excavation Dia" of Well Casing <br /> ❑ Domestic/Private ❑ Grave! Pack <br /> ❑ Public acy Type of Casing i <br /> ❑ Other ❑ Delta Specifications ; <br /> ii hof Grout Seal I <br /> ❑ Irrigation Approx. th ❑ Eastern Type of Grout <br /> Repair Work Done ❑ Type of PumpH P Surface installed by <br /> State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> F <br /> Depth. Filler Material (Below 50') I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ <br /> DESTRUCTION <br /> y (No septic system permitted if public sewer is <br /> Installation will serve: Residence Commercial, Other vailable within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK i'Type/Mfg Water table depth i <br /> PKG. TREATMENT PLT. ❑ j Capacity I No. Compartments <br /> Distance to nearest: WeilFoundation i Method of Disposal <br /> Pro <br /> Property Line <br /> LEACHING LINE ❑F No. & Length of lines _ I c <br /> FILTER BED - Total length/size <br /> ❑ .Distance to nearest: Well I "�� <br /> Foundation Property Line <br /> SEEPAGE PITS <br /> ❑ r <br /> Depth Size � J., <br /> SUMPS ;Number <br /> ❑ Distance to nearest: Well Foundation ' <br /> DISPOSAL PONDS [) Property Line <br /> q <br /> 1 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 /> Home owner"or licensed agent's signature certifies the following: ? <br /> employ an g: "I 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 ." certify that in the performance of the work for which this permit is issued,f shall employ persons subject to workman's compensa � <br /> tion laws of California." ` <br /> The applicant ust call f r fall re iced inspections. Complete drawing on reverse side. <br /> Signed All <br /> _ _ Title: ,� <br /> �t Y 1L - _ Date: 7a <br /> U y �� a FOR DEPARTMENT USE ONLY­ <br /> Application <br /> � <br /> Application Accepted by <br /> Date �'-1--: 2. Area <br /> Pit or Grout Inspection Date <br /> Final Inspection y ,Date <br /> Additional Comments /,j p ,Q 3 l <br /> ❑ Stk 466-6787 ❑ Lodi3621 ❑ M nteca 823-7104 ❑ Tracy $35 6385 3' ql <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 S <br /> ET DUE AMOUNT REMITTED CK <br /> CASH -RECEIVED BY DATE PERMITNO. <br />+ EH 13-241REV.tie51EH 14-28 <br />