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r <br /> 1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T 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 City Lot Size a&-a4,oPM <br /> Owner's Name Ap" AW­ <br /> Cont(ace, , A ., /F�Address ! d License NOZ Phone <br /> TYPE OF WELL/PUMPV NEW'WE:LL ❑ WELL REPLACEMENT Q DESTRUCTION ❑ 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 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f l Public ❑ Other ❑ Delta Depth of Grout Seal'1 Type of Grout _- <br /> I Irrigation _.-Approx. Depth I I Eastern Surface Seal Installed by _ <br /> Repair Work Done Ll Type of Pump i H.P. State Work Done <br /> Well Destruction ❑ Well Diameter _Sealing Material Itop 501 _ <br /> Depth Filler Material (Below,501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONA REPAIR/ADDITION l I--. DESTRUCTION I I INo septic system permitted if public sewer is <br /> �� available within 200 feet.) <br /> Installation will serve: Residence' Commercial ,Other <br /> L f -• t t <br /> Number of living units: J Number <br /> Character of soil to a depth of 3 feet: ` " `�?-- -- ---- — _ Water-table-depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity �� �' No. Compartments `� S <br /> PKG. TREATMENT PLT. ❑ !� " t Method of Disposal <br /> _ Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No.,& Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth Size 1 l Number ' <br /> SUMPS ❑ Distance to nearest: Well, Foundation '�� Property Line _..___.__ <br /> DISPOSAL PONDS ❑ r" <br /> I <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: "I certify that in the performance of the work for which this permit is issued, E 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:_-").certify_that.in.the-performance.of_the work for.which-this-permit is issued,I shall employ-persons subject to workman <br /> 's,compensa- <br /> tion laws of California." <br /> The applicant t call for a ecluired inspections. Complete drawing on reverse sid <br /> Signed X Title: 1 r Date:Z <br /> FOR DEPARTMENT-LISE ONLY <br /> Application Accepted b Date Area �2 <br /> it r Grout Inspection byDate Final Inspection b Date <br /> I <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 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT*NO. <br /> ..EH7314�2e 24 IREV,t i N sl <br /> EH ! O C1—4� <br /> V� <br /> i <br />