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i <br /> - 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 14YEAR 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 <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 18&2 for t an pump and the Rules and R the work herein described This application is <br /> Local Heallth�„:DIistrict. . Regulations of the San Joaquin <br /> Job Addre-ssF. <br /> I for <br /> City Lot Size PM <br /> Owner's Name Address + <br /> -4 Phone Q <br /> Contractor <br /> EAdress L,cense No� Phone d <br /> „TYPE OF WELL/PUMP:w...s.... NEW iM <br /> 1NELL❑ <br /> WELL*.REPLACEMENT,.❑ DESTRUCTION,T] <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ <br /> SEWER LINES p;SPO'SAL FLD. <br /> FOUNDATION . LINE <br /> AGRICULTURE WELL OTHEA WEL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION ER WENS t <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca D; '' . <br /> e I Excavation. <br /> ❑ Domestic/Private D Gravel Pack Dia. of Well Casing <br /> ❑ Public �LJastern <br /> Type of Casing <br /> ❑ Other � ••y Specifications <br /> Depth of Grout Seal <br /> ❑ Irrigation pp �eppType of Grout <br /> Surface Seal Installed by <br /> Repair Work Done ❑ of Pump H P <br /> Well Destr ❑ Well Diamet r State Work Done <br /> #: Sealing Material {top 5o'1 <br /> Depth nXFiller Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTi4LLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION 17 ............fseptic system permitted if public sewer is <br /> Installation will serve: Residence available within 200 feet.) <br /> Commercl lal Other��- <br /> Number of living units:� N bef bed ohms <br />'? Char ctter`�of soil to a depth of 3 feet:' <br /> SEPTIC TANK —0—Type/Mfg 4� .., � E. ater table depth- <br /> PKG. TREATMENT ALT. ❑ Cacity '� N `Cqm. '^” �° -pa1 L partmentsy <br /> -► Method of Disposal ~ <br /> Distance to nearest: Well // �:,y 5-~7 , <br /> j L Foundation—� Propert Line <br /> LEACHING LINE;'I <br /> ❑ Na. & Length of lines �----�-�--�.-...-,�.-. � <br /> FILTER BED Total length/si e Q <br /> ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> 1 � <br /> S AGE PITS ❑ Depth 1ZQ <br /> Number <br /> LIMPS <br /> ❑ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ClProperty Line <br /> 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: "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 <br /> certifies the following: "I certify that in the performance of the work for sub contracting signature . <br /> or which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must tali for all re 'red inspections. Complete drawing on reverse side. <br /> Signed <br /> Title: Date: <br /> FOR DEPARTMENdT USE ONLY <br /> tt <br /> Application Accepted by I <br /> Date"` Area <br /> Pit or Grout Inspection by bate „Final InspecLori`'by <br /> Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracyw,835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Haielton`Ave„P.O. Box 2009, Stk., CA 95201 <br /> FEE gMOUNT DUE AMOUNT REMITTED CK# <br /> INFO CASH !RECEIVED eY DATE PERMIT NO. <br /> + EH 14-25 <br /> EH 13-24 IREV.i a51 O - <br /> ��2Sj <br />