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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> 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 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 /jo 2 Z .C. (d! City Lot Size PM <br /> Owner's Name �� Address ao / 7LL. /`7�i�il � Phone36 2 — 3 <br /> Contract Address P6,`e)ca"71 :ZtQ7 ,plc License No, ac1P Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r <br /> 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing L <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> r <br /> ❑ Public ❑ Other t ...r ❑ 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 ElWell Diameter Sea <br /> ling Material (top 501 -� <br /> Depth filler Material (Selow_501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATJON ElREPAIA ADDITION DESTRUCTION IFT (No septic system permitted if public sewer is <br /> f// _ available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other ' <br /> Number of living units: Number of be ooms <br /> 6 <br /> Character of soil to a depth of 3 feet: ^'� Water table depth <br /> SEPTIC TANK �TypelMfg Capacity�7f3_ No. Compartments <br /> %J hal i <br /> PKG. TREATMENT PLT. ❑ "' �' �• �x'`-.�. �„ ..,�F f`"'—'�—,`MetFiod of:Dis�osa! <br /> Distance to nearest: Well Foundation�� Property Line _� = I <br /> LEACHING LINE ❑ G_& Length of lines Total length/size r- <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Ndriiber <br /> SUMPS ❑ Distance to nearest: Well 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 /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:: 1 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."Contractors 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 st call for required inspections. Complete drawing on reverse <br /> �rsside. <br /> Signed Title: V�'. Date: <br /> FOR DEPARTMENT USE ONLY <br /> -Application.Accepted-by- --Date P/IqArea-- L­0— <br /> Pit <br /> —Pit or Grout Inspection by Date 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT•N0. <br /> + EH13-24{REV.t/a57 —7p <br /> EH 74-28 1 <br />