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r � <br /> APPLICATION FOR PERMIT j <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �� <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I (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 /> Job Address g City Lot Size X [[-L� PM <br /> Owner's Name TPCIA i 1 lnZ Address sn_z; OG a�- Phone Lk(o -`r�C.�✓Z <br /> Contractor Address License No. Phone <br /> TYPE OF WELL! P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> UMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SE TANK SEWER LINES DIS fCL FLp. PROP. LINE <br /> FOUNDA AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL OBLEM AREA RUCTION SPECIFICATIONS ) <br /> ❑ Industrial ❑ Open Bottom ❑ Man Dia. of Weil Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack cy .ype of.Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth o r*ut Seal Type of Grout <br /> ❑ Irrigation —_A x. Depth ❑ Eastern Surface Seat Installed by <br /> Repair Work Done ❑ T pe of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material (Below 50'I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (Na septic system permitted if public sewer is {�1 <br /> available within 200 feet./ $ <br /> Installation will serve: Residence_ Commercial_ Others G <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: ' Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Ca ity No. Compartments <br /> Y <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> - y Distance to nearest: 1Nel Foundation Property Line <br /> LEACHING LINE _❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Fou tion Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ E <br /> I 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 /> 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 /> a <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 /> The applicant must call for all required in pactions, Complete drawing on reverse side. <br /> Signed C ! Title: Date: <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> { <br /> Application Accepted y Date G- Area <br /> Pit or Grout Inspect( y Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 IJMand" 823-7104 ❑ Tracy 83543% <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i • s � F <br /> FEE <br /> ' INFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE PERMIT NO. <br /> + EH 13}24(REV.!i B 5) � <br /> EH 1428 <br /> S <br />