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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT "' 5 <br /> 1601 E. HAZE I ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES YEAH FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> r � _ <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 f c' City �^C7 ` Lot Size PM <br /> Owner's Name 1 C- 4 Address . `tel Cr �� _ trl ei Phone <br /> Contractor - f Address do TilLi <br /> -' <br /> cense No. +.�- Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT I-] DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑' SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE V <br /> `FOUND"ATiON AGRICULTURE WELL''­ - -OTHER WELL P1TS%SUMPS- \ <br /> INTEN zD USE -TYPE OF WELL PROBLEM AREA CONSTRUCTION.SPECIFICATIONS <br /> 0 Industrial � ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑,Grave Pack 1 ❑ Tracy a of Casing{ Specifications <br /> ❑Public - ❑-Other-4 ❑ Delta Depth of Grou Type of Grout <br /> ❑ Irrigation _„Approx. Depth ❑ Eastern Surfac,lgerai Installed by � y <br /> Repair Work Done ❑ Type of Pump H.P. l �r State Work Done Fr <br /> a <br /> Well Destruction ❑ Well.Diameter Sealing Material,itop 501 <br /> Depth Filler Material fhelow 501 tE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> ` available within 200 feet.] <br /> Installation will serve: Residence Commercial={Other; r a i <br /> Number of living units: Number o—F&R'oms'_- J <br /> Character of soil to a depth of 3 feet ti Water table depth <br /> Y” r , <br /> r• <br /> SEPTIC TANK ❑ Type/Mfg + OAL Ce j•- Capacity--;�, No. Compartments <br /> PKG. TREATMENT PLT. [I Method of �ispal <br /> Distance to,nearest: R V1lel! _ Foundation _ _ Property Line it <br /> o / i <br /> LEACHING LINE ❑ No. & Length-of lines` Total length/size <br /> FILTER BED ❑ Distance-,to nearest: Well ' - Foundation Property Line__ <br /> SEEPAGE PITS El Depth Size Number <br /> SUMPS ❑ Distance to4nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 /> 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 /> MTheappfcant must call for all required inspections. Complete drawing on reverse side. <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY a <br /> Application Accepted by Date Area f <br /> 4 <br /> Pit or Grout Inspection by 4W:;�� Dats Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 456-6781 ❑ Lodi 369-3621 ❑ Manteca' ;`823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Servicas 1501 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE "PERMIT'NO.INFO _CASHEH 13-24 TREY.t/a 51 f.(.FEH 1428 <br />