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--� ; APPLICATION FOR PERMIT <br /> r li <br /> ,l SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I� 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> I" Telephone (209) 466-6781 Ai <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED NOV o <br /> (Complete in Triplicate) 1 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the ribed. This application is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the San Joaquin <br /> Local Health District. 11. <br /> Job Address a4 ��f'. City Lot Size PM <br /> i <br /> Owner's Name T�� Address Phone <br /> Contract o Address - �" License No. ,V&2_ Phon <br /> TYPE OF WELL/PUMP: i NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION ❑ <br /> PUMP I SYSTEM REPAIR O OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLO. -,PROP... <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 /> emestic/Priv%ate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> l'l Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> -- <br /> I I Irrigation —i1-Approx. Depth l I Eastern- /S}irface Seal Installed by <br /> u / c �I <br /> Repair Work Done X Type of Pump H.P. Y — State Work Done <br /> Well Destruction D Well Diameter Sealing Material [top 501 <br /> DepthFiller Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ('I REPAIR/ADDITION I I DESTRUCTION I i INo septic system permitted if public sewer is <br /> it ~" available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other - <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth,of�3 feet: Water table-depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ p "� Method of Disposal <br /> .i <br /> Distance to nearest: Well Foundation Property Line <br /> .i <br /> i <br /> I -LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> li <br /> SEEPAGE PITS l I Depth "Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ it <br /> I 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 Di1trict: <br /> Home owner or licensed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of Calif otnia."Contractor's hiring or subcontracting signature <br /> t 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." II <br /> The app all for all',required inspections. Complete drawing on averse side. <br /> �1 �a Z-) <br /> C. <br /> Sign d .Title Date: <br /> I. FOR DEPARTMENT USE ONLY <br /> n <br /> Application Accepted by II c. Date �� Area `' <br /> Pit or Grout Inspection by. , Date Final Inspection by DateI� <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 EI Manteca 823-7104" ❑ 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 CK 0 CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> a +.EH 13-24 IREV.i/H 5) <br /> EH 14-M <br />