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4x. -sy.l4 lit' . <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1. YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) application is <br /> Application is hereby <br /> M! to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This <br /> 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 /> made in compliance 1 <br /> Local Health District. , / M —�— <br /> ��f". City Q- 7Lot Size <br /> KJob Address 1 Phone 1 �6, <br /> Address <br /> I Z <br /> Owner's Name Phone <br /> License No. <br /> 1 Address ❑ pEgTRUCTION El <br /> &onttactor �l <br /> WELL REPLACEME <br /> NEW WELL ❑ OTHER ❑ <br /> TYPE OF WELL/PUMP: SYSTEM R AIR C] PROP LINE <br /> DISPOSAL FLD.— <br /> PUMP INSTALLATION ❑ <br />� SEWER L ES PITSISUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK -- AGRICULT E W L OTHER WELL�� <br /> i FOUNDATION �— <br /> PROBLEM AREA C TRl1CTION SPECIFICATIONS Ilk <br /> Dia of Well Casing <br /> INTENDED USE TYPE OF WELL ` <br /> ❑ Manteca !a. o Well Excavation Specifications <br /> [IIndustrial L) open Bottom Type of sing <br /> ❑ Gravel Pack EJ Tracy Type of Grout -- <br /> ❑ DOmesticIPrivate C1 Delta Depth of G ut Seal <br /> I F1 Public n Other <br /> —_Approx. Depth l 1 Easte Surface Seal I tolled by <br /> l I I Irrigation H P State Work Done _ <br /> [ Repair Work Done ❑ Type of Pump Sealing Material (top 501 <br /> Well Destruction ❑ Well Diameter <br /> I Depth Filler Material (Below 50'1 ` <br /> I available within 200 feet.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L1 REPAkR/ADD1710N I 1 RESTRUCTIO (No septic system permitted if public sewer Is <br /> C_. <br /> installation will serve: Residence Commercial Other <br /> Number of bedrooms Water table depth <br /> Number of living units: � <br /> Character of soil to a depth of 3 feet: acit No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg ,� � y� + Method of Disposal <br /> $ PKG. TREATMENT PLT. EDhn�f�� ����Without Property Line <br /> Distance to nearestpearl <br /> • length/size <br /> LEACHING LINE <br /> Ll No. & Length of lines [ Property Line <br /> ❑ Distance to nearestb� -� � <br /> rOnmc_ �.- o n a ion <br /> FILTER BED <br /> Size Number <br /> SEEPAGE PITS l 1 Depth Foundation Property Line <br /> -❑ Distance to nearest: Well <br /> SUMPS <br /> tate laws, and <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, s <br /> LI <br /> I shall not <br /> l rules and regulations of the San Joaquin Local fies the Health followingt. certify that in the <br /> Home owner or licensed agent's sigas torbecome subject lto wlorkman'scompen ation laws of performance <br /> ah" Contractor's lhit ng1 orr sub <br /> -contras perrriit is cting signature <br /> employ any person in such manner persons subject to workman's compensa <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,!shall employ <br /> tion laws of California." / <br /> The applicant must call for all uir inspections. Complete drawing on reverse side. Date: -` A <br /> Title: <br /> j f signed X' <br /> " OR PARTMENT USE ONLY r� <br /> Date <br /> CArea <br /> Application Accepted by Date <br /> t Date--,Final Inspection by <br /> Pit or Grout Inspection by <br /> Additional Comments: `'/ <br /> ❑ Stk 466 6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> P.O. Box 2009, Stk., CA 95201 <br /> Applicant- Return all copies to: Environmental"Health Permit/Services 1601 E. Hazelton Ave., <br /> CK RECEIVED BY DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED' C/ASH? / 9 <br /> INFO r �� <br /> +.EH 13-24(REV,f/K 5) r 07z:) <br /> EH 14-26 <br /> c <br />