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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781. <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> _ (Complete in Triplicate) <br /> Application is heieby 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.548 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District, oy <br /> Job Address S . City Lot SizezCY�VJp{y! <br /> tOwner'slNarntie" 't-1 R Kms.. Address Vrr -Phone <br /> 1 � �� <br /> Contracto Address QQ 0% / License No.,3i)%.7 2(0 phone 3A —S to <br /> TYPE OF VIIELt/PUMP: 1 NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L] OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PRO?. LINE 4 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing `-E Specifications ' <br /> i <br /> i Public [IOther f 1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation <br /> —.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. � Y <br /> �-;-State Work done <br /> Well Destruction ❑ Well Diameter Sealing Materia! (top 501" <br /> Depth Filler Material (below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR ADDITION 0<DESTRUCTION I I (No septic system permitted if public sewer €s T <br /> �" ! available within 200 feet.) i h I <br /> Installation will serve: 'Residence Commercial Other <br /> Number of living units: A— Number of droo s +3 ! 1 <br /> Character of soil to a depth of 3 feet: r i Water table depth '{` <br /> SEPTIC TANK ❑ Type/Mfg i Ca acit �7 <br /> p Y No. Compartments <br /> PKG. TREATMENT PLT. ❑ j - € A, <br /> Method of Disposal <br /> Distance to nearest: Well Foundations !Property Line <br /> LEACHING e" & <br /> LINE No. Length of lines O _ Total length/size O - <br /> FILTER BED ❑ Distance to nearest: WellO' ` r <br /> �_._ Foundation _�_Q Property Line S " <br /> SEEPAGE'PITS I1l"Depth —C'gV`)0/1 SizerrrSber 'a <br /> SUMPS —.--��.L-�—Distance to nearest: Well 100Foundation_ 1r rJ. <br /> ! r ___�.�_ Property Line <br /> DISPOSAL-PONDS. } LJ p— ! <br /> I hereby-certify that-t-have prepared this application and that the work will be done €n accordance with San Joaquin county ordinances, state laws, and <br /> rules and.regutations of the San Joaquin_Local.Health District. "1 <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: "!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" st call for all required inspections. Complete drawing on reverse side. <br /> Signed X <br /> Title: OR Date: 9I <br /> �� FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date '�!) Area <br /> Pit Grout Inspection by Date ,� �� y <br /> �_ t/S Final Inspection b � Date r •�"'� <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 1 ❑ Manteca 823-7104 11Tracy 835-6385 <br /> Applicant - Raturn all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 4 f <br /> i <br /> 7 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY <br /> INFO REC <br /> �/�] CASH DATE PERMIT"NO. <br /> + EH 13-24 fREV. /K51 /U <br /> EH 11-29 <br />