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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL 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 /> e —� <br /> • City Lot Size PM <br /> Job Address J <br /> Owner's Name <br /> Address / •Phone <br /> Contractor Address <br /> License N �Phony J._. <br /> TYPE OF WELLIPUMP. NE WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> _ PUMP INSTALLATION_C� _ ' SYSTEMREPAIR C3THER ❑ <br /> _ O <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 /> ❑ Ind trial � ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> Type of Casing <br /> Specifications <br /> omestic/Private ❑ Graver Pack ❑ Tracy g v <br /> [-I Public <br /> [ ] Other F1 Delta Depth of Grout Seal Type of Grout — <br /> I I Irrigation -- -Approx.'.DeptY7 I Eastern S ace Seal Installed by <br /> H p State Work Done d <br /> Repair Work Done ❑ Type of PumP144ae " r <br /> Sealing Material (to 501177- <br /> Depth <br /> Well Destruction ❑ Well Diameter 9 p `` V <br /> Depth Filler Material (Below 501 -- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION I I avo septic system <br /> m emitted if public sewer is <br /> Installation will serve: Residence Commercial— Other <br /> Number of Iiving units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table��dep�th <br /> 4 SEPTIC TANK ❑ Type/Mfg Capacity Me Q�o aa��tt <br /> PKG. TREATMENT PLT. ❑ MartREGEMP� <br /> Distance to nearest: Well Foundation Property.Li WUr"99] <br /> LEACHING LINE ❑ No. R Length of lines Total length/slI+i1t1�iNJJ���'` 1JIN COUNTY <br /> P o�ekt' �Ir r <br /> FILTER BED ❑ Distance to nearest: Well Foundation 1' P'01Nlbr�.H( i Cil DIVISION <br /> t SEEPAGE PITSI 1 Depth .—Size Number <br /> SUMPS-"-"�-�. � f Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ i <br /> I hereby certify that 1 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: "1 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 /> I 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 California." <br /> The applic must call for all required inspe cions. Complete drawing on reverse side. <br /> I <br /> Signed ? Title: Date:4� <br /> .POR DEPARTMENT USE ONLY G� <br /> Application Accepted by <br /> Date Q ` Area <br /> IDate Final Inspection by Date_ �-- <br /> Pit or Grout Inspection by <br /> + Additional Comments: <br /> i ❑ Stk 466-6781 0 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 /> i _ <br /> FEE AMOUNT DUE AMOUNT REMITTED GK RECEIVED BY BATE PERMIT NO. <br /> INFO <br /> A !� y (� 2� 4 q2-Z3 <br /> +.EH 13-24 IREV.r/�5S+!/� �r,�v vse 0-0 R 237�Y <br /> EH 14.29 II <br />