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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT l <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES'l YEAR FROM DATE ISSUED . <br /> f> (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 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 /> l E <br /> Job Address �t/ ` Ci Loi Size/ - PM <br /> Owner's Nam Address 1_�6L /7 Phone <br /> Contract Address .0 tj Z6;r !Y/ License No. 22C- Phone CY-5­16 �\ <br /> TYPE OF WELL/PUM : NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> }, F <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS —y <br /> INTENDED USE TYPE OF WELL 'PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �a <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy & Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta ` Depth of Grout Seal Type of Grout <br /> ❑ irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well-Destruction ❑ - Well Diameter. Sealing MaterialAtop 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ EPAI /ADDITION DESTRUCTION El (No septic system permitted if public sewer is <br /> within.2(10 feet.) <br /> Installation will serve: Residence_ Commercial_ ther �' <br /> Number of living units: /-"— Number of b rooms W ,F� <br /> "._- <br /> Character of soil to a depth of 3 feet: Waier.table depth <br /> SEPTIC TANK ElType/Mfg Capacity 2 No, Compartments <br /> PKG. TREATMENT PLT. ❑ M <br /> - <br /> l Method of Disposal <br /> Distance to nearest: Well '. Foundation Property Line <br /> k r f _ <br /> LEACHING LINE P�'No. & Length of lines ? r Total length/size_ < <br /> i <br /> FILTER BED ❑ Distance to nearest: Well 0 r 'Foundation__. �_..__ Property Line <br /> SEEPAGE PITS Depth SizeNumber f _ <br /> SUMPS LlDistance to nearest: Well 114�9-0- ,Foundation li Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this ap""plication and that the work will be done in accordance withSan Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. —-;.—I .1 1 } <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 shall 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 /> The applicant ust call fo all required inspections. Complete diswirig on reverse-We. <br /> Signed Title:— /t Date: z <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Rate U Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> + EH13-241428REV.1/851 ['� ry'�-5q7 <br /> EH 1 <br />