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3 syp. <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 Y <br /> PERMIT EXPIRES,11 YEAR FROM DATE ISSUED <br /> rt (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 /> ti <br /> Job Address AV06 City Lot Size <br /> PM <br /> Owner's Name Address Phone 3 f� <br /> Contractor �l�-C�ct� Address l J a License No.JCC 232- Phone-AP— h-(- <br /> TYPE <br /> -TYPE OF WELL/PUMP: I NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION L] <br /> PUMP INSTALLATION Er SYSTEM REPAIR ❑ i OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <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 <br /> IP'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I <br /> L3 Public r❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation5 I Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ ,Type of Pump H.P._l 1— State Work Done <br /> Well Destruction El Well Diameter Sealing Material {top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ 'DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) i it <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms i <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ 7 e/Mf <br /> YP 9 Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ I� Method of Disposal E <br /> .1 <br /> Distance to nearest: Well, Foundation Property Line <br /> w s <br /> LEACHING LINE ❑ No. & Length of lines <br /> g Totallengih/size <br /> ih <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well t Foundation Property Line <br /> DISPOSAL PONDS ❑ III <br /> 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: "t 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,[shall employ persons subject to workman's compensa- <br /> tion laws of California.,' <br /> The applicantFr9lit call for all req inspectio Dat <br /> s. Complete drawing on reverse side. <br /> Signed tle: <br /> e: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by '` Date `"'/Wo Area <br /> Pit or Grout Inspection by ;` Date Final Inspection by Date 3 r <br /> t1 <br /> Additional Comments: !! �C Q 1"�?�� �?-y <br /> ( }� <br /> IDStk 466-6781 ❑ Lodi i� 369-3621 ❑ Manteca 823-7 '❑ Tracy <br /> Applicant- Return all copies toq 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. F <br /> INFO �qII CASH <br /> + <br /> EH -4-24 1 REV.1/a 51 J <br /> EH 1428 �f /�3 <br /> iM 'FS—(o 412.B <br />