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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ` 1601 E. HAZELTON 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 Sart 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 Z2�.7 _... /✓ _ _.._ City Lot Size PM <br /> -Owner's�Name Address - — Phone <br /> Contractor 'Address License No.J �� Phone ` w <br /> TYPE OF WELL/PUMP: NEW ELL•1JERE <br /> L REPLAC MENT � DESTRUCTION":? <br /> PUMP INSTALLATION GSYSTE REPAIR,-']- ._ OTHER r7 <br /> DISTANCE TO NEAREST: SEPTIC TANK __. . S DISPOSAL FLD.� - PROP. LINE <br /> -.FOUNDATION R WELL OTHER WELL � 'PITS/SUMPS ti <br /> INTENDED USE y r TYPE OF WELL PROONSTRUCTION SPECIFICATIONS �- <br /> Industrial L Open Bottom D Mia. of Well Excavation Dia. of Well CasingLl Domestic/PrivatO- O Gravel Pack t. �,-1TypeofCasing"_ _-_. ._—_.. . .. Specifications <br /> Public n Other .I DDepth of Grout Seal- Type of GroutI I Irrigation Approx. Depth I ESurface Seal Installed byRepair Work Done 0 Type of Pump . . ^- : ' State Work Done <br /> Well Destruction F_1 Well Diameter Sealing Material (too 50'I <br /> r Depth-- Filler Material (Below 50'I <br /> TYPE OF SEPTIC WORK:, NEW INSTALLATION , REPAIR/ADDITION I : DESTRUCTION I I INo septic system permitted if public sewer is <br /> ' / available within 200 feet.) <br /> Installation will serve: Residence 0/' <br /> Commercial _ ther <br /> Number of living units: Number of bedrooms (21 <br /> Character of soil to a depth of 3,feet_ _ Water table depth <br /> SEPTIC TANK' 11 Type ¢ Capacity . No. Compartments <br /> PKG. TREATMENT PLT. ❑ _ - Method of Diis/p�o7sal. � <br /> r Distance to nearest: Well 2 oundation Property Line <br /> LEACHING LINE __I No. & Length of lines To length/size r <br /> FILTER BED CI Distance to nearest: ell 2 oundation _�� Property Line Z_ <br /> -- -- t.L .---- (� _ <br /> SEEPAGE PITS I : Depth ��.. _—Size -_ Nuup er <br /> SUMPS Ll Distance to near t: Well oundation _6.0./� Property Line <br /> DISPOSAL PONDS ❑ /y/ <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.` t f <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, 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, I shall employ persons subject to workman's compensa- <br /> tion laws of Calif rnia." i <br /> The applicant m cffor all r90cYrred inspe tions. Complete drawing on reverse side. <br /> Signed X_ ._ _ Title: Date: 9— <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by ' ' __..._ ____Date _ Area a�t1 <br /> a Fina! Inspection b \� y <br /> Pit or Grout Inspection by (ff— q� �G� Date p y �� Date <br /> Additional Comments: 4Z 7— 7r9 <br /> n Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 17-1 Tracy .835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 <br /> FEE <br /> INFO AMOU`NTT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> 4_ 11n1)spEH 1426 ((( \U <br />