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ERMIT <br /> i APPLICATION FOR ACTH DISTRICT �� � ; to <br /> SAN JOAQUIN LOCAL H <br /> 6> <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA ' <br /> MIA <br /> Telephone (209) 466-6781 f `w <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 /> r made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for weu pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. I <br /> f '1 70 -6 �.d A�v� _ City Lot Size PM <br /> II Job Addresscr� <br /> 4 r <br /> - <br /> Phone <br /> Owner's Name <br /> �- ? 33(1 <br /> r �or— aq s Address O License No.2 -Phone <br /> Contractme <br /> TYPE OF WELL/PUMP: NEW WELL❑ WELL REPLACEMENT ❑ DESTRUCTION 0 <br /> OTHER ❑ <br /> PUMP INSTALLATION X, 3� : SYSTEM REPAIR Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER-LINES­ <br /> FOUNDATION <br /> FCD. PROP. LINE <br /> l FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of,Well Excavation Dia.,of Well Casing <br /> tBatnesticfPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Other Cl belta� Depth of Grout Seal Type of Grout <br /> f'1 Puhlic �,, <br /> . A rax. Depth I'I Eastern lam/ Surface Seal Installed by <br /> E I f Irrigation -- Pp P <br /> r Repair Work Done ❑ Type of Pump *� H•P� 1 �' State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 - <br /> Depth Filler-Material IBelow 50'I — +� <br /> 4 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION l I INo septic system permitted if public sewer is �✓ <br /> ( available within 200 feet.) <br /> Installation wdl^serve:•�Residence-� Commercial_ Other <br /> Number of Living units:-- -;""Nuri.ber of bedrooms" "" <br /> Character of soil to a depth of 3 feet: Water table depth <br /> t4 t Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg , <br /> i PKG. TREATMENT PLT. ❑ Method of Disposal �- <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size Number <br /> ( SUMPS D Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 1 <br /> 1 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. <br /> ify that in the performance of the work for which this permit is issued, 1 shall not <br /> Home owner or licensed agent's signature certifies the following: "I cert <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 /> The applicant must tail for all required inspections. Complete drawing on reverse side. <br /> ' Signed Title: - Dater r <br /> DEPARTMENT USE ONLY <br /> t <br /> Date Area <br /> Application Accepted by <br /> Pit or Grout Inspection by Data Final Inspection by�5 Date <br /> r <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 2009, Stk., CA 95201 <br /> .I .- I _ <br /> FEEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT IVO. <br /> i <br /> INFO <br /> +.EH 13-24(REV.v/x51 <br /> EH 14-26 <br />