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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 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 /> 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 /> !I , <br /> SJob Addresskit) City Lot Size PM <br /> Q37Owner's Nam Address Phone S r ' 1 <br /> il <br /> ' �s <br /> Contract r Address License No ? Phone <br /> TYPE OF WELL/PUMP! NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' <br /> ` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE `` Y <br /> FOUNDATION _AGRI-CULTL Rf WELL __-­_.T.-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 /> D Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications �I <br /> f'] Public C1 Other ❑ Delta Depth of Grout Seal s' Type of Grout <br /> I I Irrigation _-Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 _ <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is <br /> _-� available within 200 feet.) " q <br /> Installation will serve: Residence L � Commercial Other <br /> ` I• � , <br /> Number of living units: Number edroo <br /> Character of soil to a depth of 3 feet: r _ Water table depth <br /> SEPTIC TANK Type/Mfg U Capacity' 04D . No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal., N <br /> r i . <br /> Distance to nearest: Well FoundationPro err "Pik <br /> c i t t C"' If <br /> LEACHING LINE IX No. & Length of lines y Total-length/size <br /> FILTER BED ❑ Distance to nearest: Well -'Foundation 7_ ""Property Lirie• ... ,F <br /> - <br /> SEEPAGE �- <br /> PITS Depth Size – _ Number . i. f <br /> SUMPS L� Distance to nearest: Well_ Foundation—_l[ w– Property Line___?_S7___ <br /> DISPOSAL PONDS ❑ <br /> I hereby-cartify 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 sZontracting 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 s all for all re fired 'nspections. Complete drawing on revers sid . s <br /> f' <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> i <br /> Application Accepted by Date Area <br /> 7 <br /> Pit r Grout Inspection by to(s!� 'd final Inspection by Date�� <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 �1 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE)NFO AMOUNT DUE AMOUNT REMITTED CK A CASH RECEIVED BY DATE PERMIT'NO. ter' <br /> + EH14-24{pEV.iiHs1 f�• �� ! r _.�g�j ���`J�7p <br /> EH 14-2e <br />