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APPLICATION FOR PERMITGE <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT R ' k V t h��r <br /> 1601 E ..HAZELTON AVE., STOCKTON, CA SEP 13 11"n9 <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED E� VIROi°�ME", � HEALTH <br /> (Complete in Triplicate) PERMIT/ � <br /> p application is <br />° Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described. This app <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for woupump and the Rules and Regulations of the San Joaquin <br /> Local Health District. I���_ <br /> (��` City �/l1 7y�/JKJJ Lot Size PM <br /> Job Address <br /> d , � dress ���p1 Phone <br /> 0 ner's Named - <br /> C ra for d Ss <br /> ense No. Phone <br /> r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEME T ❑ DESTRUCTION ❑ <br /> PUMP INSTALLAT10�7J�_ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> IN USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION pia. of Well Casing +JZ <br /> ❑ Industria! ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing Specific�Gru�ut___ <br /> ns <br /> a lestic/Private ❑ Gravel Pack [1 Tracy Type of✓✓f"1 <br /> Public R Other Cl Delta Depth of Grout Seal ypI i Irrigation —..Apprax. Dep I a ern Syrface Seal Installed by ..!{ <br /> i P State Work Done <br /> Repair Work Done Type of Pump j <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> 2 <br /> Depth Filler Material (Below 501 <br /> lsystem perm <br /> l TYPE OF SEPTIC WORK: NEW INSTALLATION ['l REPAIR/ADDITION I I DESTRUCTION I I (Nailabpelwithin 200 feet)?led if public sewer is <br /> installation will serve: Residence— Commercial, Other { <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> Capacity No. Compartments <br /> SEPTIC TANK 171 Type/Mfg _ _{ a _ <br /> Method of Disposal' <br /> PKG. TREATMENT PLT. ❑ I <br /> Distance to nearest: Well Foundation Property Line <br /> r + <br /> LEACHING LINE ❑ No. & Length ofiliries Total length/size <br /> FILTER BED L1 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size Number z, <br /> SUMPS LI Distance to nearest: Well { Foundation Property Line L <br /> DISPOSAL PONDS ❑ _ _ --- - <br /> Ihereby certify that I have prepared chis application and that the work will'be done in accordance with San Joaquin county ordfnances,state laws, and <br /> rules and regulations of the San Joaquin Local Health Di§trict. <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." Contractors 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 /> I The applicant ptipil,call for II r aired inspegtions. Complete drawin4onre'.'rse side.Signed / `-� Title: Date: <br /> FOR DEPT USE ONLY <br /> Date r A� Area ^' <br /> Application Accepted by J <br /> Pit or Grout Inspection by <br /> Date Final Inspection 1: Date jf i <br /> Additional Comments: <br /> EJ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Petmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEECK RECEIVED BY DATE PERMIT NO. <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> +-EH 13.24 1REV.I/R 51 /I� O 9<>—a4-79 <br /> EH 14-28 <br /> r <br />