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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone {209) 466-6781 I <br /> PERMIT EXPIRES TYEAR 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 <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. � r <br /> City Lot Size PM <br /> I. <br /> Job Addres <br /> r �'� �® <br /> Owner's Name <br /> ddress Phone <br /> I , I I Address � lt,�= 'License No. hon <br /> Contract <br /> TYPE OF WELL/PUMP: NEW WELLLJ WELL REPLACEMENT 11DESTRUCTION ❑ } <br /> PUMP INSTALLATION IDSYSTEM REPAIR ❑ OTHER ❑ <br /> -DISPOSAL 5Lb.-- PROP EINE s I <br /> DISTANCE TO NEAREST: SEPTIC TFiNK­_' SEWER LINES , <br /> FOUNDATION AGRICULTURE WELL OTHER WELL— <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ industrial [2 Bottom ❑ Manteca Dia. of We11 Excavation <br /> Dia. of Well Casing i <br /> Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack El Tracy Type of Casing T e of Grout r <br /> M Public t ❑ Other f Delta Depth of Grout Sea! YP <br /> �IF <br /> I I Irrigation � --Approx. Depth l I Eastern Surface Baal Installed by - <br /> H <br /> --1 State Work Done <br /> Repair Work Done II f 7ype-of-Pump- , <br /> Well Destruction ❑ Well Diameters 1F Sealing`Material Ito 50'1 <br /> R <br /> "^"Depthy" '"Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION [ I DESTRUCTION I I (No septic sy t m rented it public sewer is <br /> —� <br /> _. <br /> installationnvdhserve: Residence Commercial � Other -T'—" <br /> 1 Q <br /> Number of living units: Number b Broom �' _I <br /> Character of soil to a depih of 3 feet: r <br /> Water table depth f I <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments �', <br /> ""^� }3 ! 1 Method of Disposal <br /> PKG. TREATMENT PLT. ❑ n <br /> Distance to nearest: Well 5! o Foundation-� - — Property Line� .- <br /> 1 "C�,LR f •� �, <br /> T6tal length/size <br />` LEACHING LINE No. & Length of lines <br /> r ._ F <br /> ❑ Distance to nearesQFwndation <br /> FILTER BEDf t <br /> il <br /> Sixe� <br /> SEEPAGE PITS-'h--� >e_ Depth rumber <br /> — „r-- <br /> l SUMPS s ❑ Distance to nearest: /Vell Foundation��— Property Line i <br /> 1 r L <br /> DISPOSAL PONDS ❑ � k r !' <br /> I hereby certify that I have prepared this-pplication.and that the'work will be done in accordance with SaniJoaquin county ordinances, state laws, and <br /> l rules and"regulations of the_San�Jo�uin Local work for which this permit is issued,Health District. rh <br /> Home owner or licensed ag nYs'srgnature certifies the following: "I certify that in the performance of the I shall not <br /> employ any person in such manner as to becomesubjectto workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following:_I certify that.in the.performanca of the work forwhich this permit is issued, I shall employ persons subject to workman's compensa-_.M.11 <br /> h tion laws of California."' , <br /> The applica ust call r- II'r '�(red inspections. Complete drawing on reverse si Q <br /> t <br /> 1 Signed X itle: Date: <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> Area 12, <br /> Application Accepted b Qate �" <br /> •—� �l <br /> gor Grout Inspection by <br /> Date 6` /b Final inspection by <br /> Additional Comments:: <br /> ❑ Stk 466-6781 1 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazeltan Ave., P.O. Box 2009, Stk., CA 95201 <br /> CKRECEIVED BY <br /> DATE PERMIT'NO. <br /> t <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> I! <br /> +.EH 13-24 IREV-i/x b INFO ` <br /> d EH 14-26 ` <br /> 1 r <br />