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-P <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT y <br /> 1601 E. HAZEL i ON AVE., STOCKTON, CA ° <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is heiehy 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 wewpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. y �} p {� y1 <br /> \ fJ v I -.'e M !1 Q City Lot Size l! /� to PM <br /> Job Address i }� i t <br /> la I r �( Al d � A� {�1hone <br /> Owner's Name . <br /> Contractor <br /> Address — f ^ li e No Phone J t <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR F1OTHER ❑ <br /> SEWER LINES el <br /> DISPOSAL FLD POOP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TAMC L PITS/SUMPS <br /> FOUNDATION. AGRICULTURE WELL OTHER WELL <br /> I ED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Open Bottom [D Manteca <br /> Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Industrial P <br /> ❑ Domestic/Private ❑ Grav <br /> I"1 Public r Depth of Grout Seal Type of Grout--_ <br /> I <br /> rout — <br /> I 1 Irrigatio _Approx.- Depth l I Eastern ace Seal Installed by— <br /> Re <br /> y Re r Work Done. ❑ Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIRIADDITION I-I DESTRUCTION I I%(No <br /> sbptic hit system feet.) <br /> if public sewer is <br /> avaInstallation will serve: Residence Commercial— Other <br /> Number of living units: umber of bedrooms _-- <br /> + Water table depth <br /> Character of soil to•a depth of 3 feet: / ! <br /> SEPTIC TANK r❑ . Type/Mfg T rf-l.�- Capacity �� No. Compartments ' T <br /> PKG, TREATMENT PLT. ❑ 1 r Method of Disposal <br /> Distance to nearest: Well r l Foundation� Property Line ..— <br /> LEACHING LINE ❑ No. & Length of lines �otal length/size <br /> FILTER BED t ❑ Distance to nearest: Well f OV Foundation' Property Line,!� <br /> A, <br /> I SEEPAGE PITS 11 Depth Size umber <br /> Property Line <br /> SUMPS Ll Distance to nearest: Well 1Sy FoundationProFlu P Y <br /> DISPOSAL PONDS ❑ <br /> Thereby 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 /> t employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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 /> Mtion laws of Cnust <br /> The applica I for all req ired s mplete drawing on reverse sidec'r <br /> Signed Title: e rt Date: <br /> r FOR DEPARTMENT USE ONLY <br /> r Area <br /> i Application Accepted by Date�� <br /> s.; Date <br /> Pit orGrour Inspectio Date Final Inspection by <br /> Additional Comments: µ <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Cl Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> I INFO <br /> +.EH 13-24 1"Ev.t i n s) <br /> EH 14-2e - <br />