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} <br /> ti APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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 /> i <br /> Job Address ° IV de Nel Al A9 City S7 Lot Size_Zia X � �3 PM <br /> I <br /> Owner'sNamew TE ' A Address �T — Phone ?3Z <br /> Contractor 10"1> Address A tr License No. 7••7G Phone, 7 i <br /> TYPE OF WELL/PUMP:. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PI MFrtINSTAL-LATIOM­❑" SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE , <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS "w <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I"1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout a <br /> I I Irrigation --Approx. Depth l I Eastern Surface Seal Installed by - <br /> Repair Work.Done ❑ Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter. Sealing Material (top 501 fT <br /> Depth ` Filler Material (Below 501NO <br /> TYPE OF SEPTIC WORK: -NEW INSTALLATION IX REPAIR/ADDITION I I DESTRUCTION i 1'114o septic system permitted if public sewer is �a <br /> A*k available within 200 feet.) <br /> v: <br /> Installation will serve: Residence_ (Commercial_ Other 1' <br /> Number of living units: Number of bedrooms f� -D"0),A) <br /> Character of soil to a depth of 3 feet: �J Water table depth <br /> SEPTIC TANK, ❑ Type/Mfg } Capacity Vit. No. Compartments <br /> PKG. TREATMENT.PLT. ❑ ; <br /> Method of Disposal <br /> Distance to nearest: Well foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size 7Number <br /> SUMPS ❑ Distance to nearest: Well Foundation _-Property Line <br /> DISPOSAL PONDS ❑ #� <br /> I hereby certify that[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'ssignature 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."Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in the,pegormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." i Ik <br /> The applicant must call for at required inspections. Complete drawing on reverse side. ' <br /> Signed X Title: t s Date: <br /> FOR DEPARTMENT USE ONLY <br /> .. y♦ f � Y s k+ r <br /> Application Accepted-byr - -- —&-Pate . "- f Area <br /> Pit or Grout Inspection by -Date Final Inspection by f # Date <br /> j, <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 CKRECEIVED BY DATE PERMIT'NO. <br /> INFO CASH_;' <br /> r g8 � q <br /> ♦ EH 13-24IREV.iinsl <br /> J EH 14-25 <br />