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ii► <br /> APPLICATION FOR PERMIT <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 /> (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 v `� �l� `' City Lot Size PM �� ' <br /> Owner's NamAl _ ," "`_' r4.Address Phone <br /> Contraclor A fG Address• / � / License No. �`� Phone1 <br /> TYPE'OF WELL/PUMP NE WELL ❑. WELL REPLACEMENT ❑ DESTRUCTION [] <br /> �� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ -----OTHER ❑ I <br /> DISy'ANCE"TO NEAREST: SEPTIC TANK titi ' SEWER LINES DISPOSAL FLD. PROP. LINE # <br /> •.��, ;� t- . .,�, ., ti FOUNDATION 'AGRICULTURE WELL--C �-�.'� GTHER WELL PITS/SULjMPS <br /> INTENDED USE TYPE OF�WELL PROBLEM AREA ONSTRUCTION SPECIFICATIONS <br /> �::. c <br /> ❑ Industrial ❑Open Bottom d Manteca--_ Dia. of Well Excavation � Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel.•Pack /_12'tr ca y Type of Casing Specifications.. ? <br /> I'1 Public. fl Other �/ Cl Delta Depth of Grout 5eal_ Type of Grout + <br /> I I Irrigation ox, Depth r 1.-1 Eastern Surface Seah'In is ailed by A ``�✓ <br /> Repair Work Done O Type of Pump H.P. �` State Work Done <br /> I <br /> Well Destruction--' D Well Diameter S Sealing Material flop 50') <br /> Depths Filler Material IBelow 501 <br /> ,-TYPE OF SEPTIC WORK.:-NEW INSTALLATION04 REPAIRIADDITION f I DESTRUCTION I I (No septic system permitted if public seweriis <br /> j, <br /> available within 200 feet.I ' <br /> lnstallatiop will serve: Residence +Commercial # Other <br /> Number living units: f Number of be rooms <br /> t Character of soil to a depth of 3 feet: '�H? ' ``Water table depth a <br /> SEPTIC TANK ❑ Type/Mfg Cap city No. Compartments <br /> PKG. TREATMENT PLT. ❑ " 1�� • �. Method of Disposal + <br /> r' Distance to nearest: Property_ _r Foundation Property Line <br /> LEACHING LINE 0 rNo. & Length of lines i_ U 1 <br /> f� _ "To[a1"lengih-7siie <br /> FILTER BED ❑ Distance to nearestj Well Foundation Property,Line <br /> SEEPAGE PITS 11 Depth Size f Number <br /> SUMPS k lk� Distance to nearest: Well Foundation dg_dCProperty Line I <br /> DISPOSAL PONDS t ❑ <br /> 1 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. j t j <br /> t in}the p'rformance of hec) ork for which this permit is issued, 1 shall not <br /> Home owner qr licensed agent's signature certifies the following: "I cettify�tha <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 hermit is issu9d,`.1 shall employ persons•subjktto workman compensa- <br /> tion laws of Cal[for '. J <br /> The applicant sr frequiredsiFispections.Complete drawing jon re e�side. t r. <br /> Signed X , - Title: Date: <br /> FA <br /> gE RTMENT USE ONLY `f 1 <br /> Application Accepted by �" ar Date �� Area`_ <br /> --�. <br /> Pit or Grout Inspection by Date Final Inspection by ! Date,. <br /> Additional Comments-'+A. c r• ! <br /> ❑ Stk 466-67814 © Lodi 369-3621 ❑'Manteca 823-7104 ❑ Tracy 835-6385 ; <br /> Applicant - Return at] copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i <br /> .ik w i � ` <br /> FEEAMOUNT..DUE AMOUNT REMITTED CK REC`EIVED BY DATE PERMIT N0. <br /> INFO ­CASH- T- <br /> +.EH13-24(REV.1ik5) i �j/' {�-' 4 1� �/ • �4� :.1 '' <br /> EH 14-28 '-t✓ * '. t. `•, / M '_... c+ <br />