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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEILTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> ..-PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> t oaquin Local Health District for a permit to construct and/or install the work herein describe <br /> Application is hereby made to the San Jd. This application is <br /> ounty Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations oftheSan Joaquin <br /> made in compliance with San Joaquin C <br /> 1 Local Health District. <br /> City Lot Size PM <br /> Job Address Q <br /> Ain <br /> i jy j�[ it Phone 6 9 / <br /> Owner's Name L� i r`r Address 7 p <br /> 4 7 Q Phone 3 g3 )3 <br /> Contractor <br /> Address [� License No. <br /> TYPE OF WELL PUMP NEW WELL ❑ WELL REPLACEMtNT ❑ DESTRUCTION ❑ <br /> 1 PUMP INSTALLATION,n- <br /> SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES — DISPOSAL FLO. PROP. LINE <br /> SIO 1'""'. AGRICULTURE WELL OTHER_WELL PITS/SUMPS <br /> FOUNDATION — .._ -- --_ I- –­­ — ,�. <br /> BLEM AREA CQNSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL-" PROpia. of Well Casing <br /> I ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Industrial Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack Ll Tracy Type of Casing <br /> f Depth of Grout Seal Type of Grout <br /> FI Public Cl Other � Cl delta <br /> Irrigation _ Approx. D th I I Eastern Surface Seal Installed by Ef <br /> RlrhfF H.P. State Work Done Gd AJ VC 1– pJ"SC. <br /> Repair Work Done ❑ Type of Pump v ~ �. <br /> Well Destruction. ❑ Well Diameter Sealing Material (top 50'i <br /> Depth " Filler Material (Below 501 <br /> TYer <br /> PE OF SEPTIC WORK:- NEW INSTALLATION I7 REPAIR/ADDITION ( I DESTRUCTION I I available septic SY 1in 20Opte t.), � public sewer is <br /> . ,,.- r <br /> Installation_wili-sfeive: Residence__-,rCammeccial_��.Other_�.--:–– -- - �•i--�----�"–'^^�'-. r `� <br /> Number of living units: Number of bedrooms <br /> }. Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: WellFoundation Propertylr�e <br /> Total length/si <br /> LEACHING LINE ❑ No. & Length of lines <br /> r FILTER BED ❑ Distance to nearest: Well Foundation Propert�yI�lrle � <br /> Number <br /> SAN JOAQUIN C«4"NTY <br /> SEEPAGE PITS 11 Depth Size <br /> SUMPS Ll Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ <br /> . 1=hereby-certity that-I-have=prepared-this-application-and-that_the:work willbe.done=in`accordance-with-SSn Joaquin—coumV'bdrdiriances;state-la+us, an <br /> – d <br /> y rules and regulations of the San Joaquin Local Health District. <br /> I, 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, !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 California." , <br /> 4 Theapplicant must c for all required inspections. Complete drawing on reverse side. f Q0 <br /> t Title: Date: '7 <br /> Signed X <br /> FOR DEPARTMENT USE ONL' 7 <br /> D <br /> Area <br /> Application Accepted by ate <br /> Pit or Grout Inspection by <br /> Date Final Inspection gy � Dated <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 20D9, Stk., CA 95201 <br /> CK RECEIVED BY DATE PERMIT"NO. <br /> FEE <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> ♦.EH-13-241REV.t/H510 -7%­� <br /> EH 14-2$ <br />