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APPLICATION FOR PERMIT <br /> t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> i(' (Complete in Triplicate) C <br /> Application is hereby made to the San Joalquin Local Health District for a permit to construct and/or install the work herein described.This application is 1 <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 r/� PM <br /> J 9W6 ,e!�� ! ACT 5 City `�� Lot Size <br /> Job Address <br /> ' o f,JE �� 7� r�fa4 <br /> C� 4`� ABX — �/ 57� Phone <br /> Owner's Name 6 Address <br /> i <br /> Phone <br /> Contractor's Name License No. <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i <br /> t TYPE OF ELL/PUMP: SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION71 �^ DISPOSAL FLD. PROP. LINE <br /> i DISTANCE TO NEAREST: SEPTIC TANK �— SEWER LINES PITS/SUMPS i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> —� Dia. of Well Excavation <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Casing <br /> Specifications <br /> Type of Casing <br /> ❑ Domestic/Private ❑ Gravel Pa ck ❑ Tracy Depth of Grout SeaP, Type of Grout <br /> ❑ Public ❑ Other D Delta <br /> ❑ Irrigation _—Approx:Depth ❑ Eastern Surface Seal Installed by _ <br /> Type of Pump H.P. State Work Done p[} <br /> Repair Work Done ❑ TYP — - <br /> Well Destruction ❑ Well Diameter (top 50'1 <br /> Seating`Material '# <br /> Depth I Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION availableiwih$n 200 feeter .) if public sewer is <br /> Installation will serve: Residence k Commercial— Other <br /> Number of living units: Number of bedrooms C% - Water table depth <br /> Character of soil to a depth of 3 feet: `' CL <br /> ❑ Type Capacity -No. Compartments <br /> SEPTIC TANK g _. ' <br /> ---Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Property Line { <br /> Distance to nearest: Well Foundation - <br /> 1 W .. Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Property Line <br /> FILTER BED ❑ Distance to nearest: Well <br /> ❑ Depth Number <br /> SEEPAGE PITS I Size Property Line <br /> ❑ Distance to nearest: Well Foundation , <br /> I SUMPS � <br /> DISPOSAL PONDS ❑ <br /> I 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. <br /> I Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which thin permit is issued, I signature <br /> sha not <br /> employ any person in such manner as to become subject to workman's compensation Laws of California."emploContry <br /> persons <br /> sub subject to workman's ing or sub-contracting <br /> the following:"I certify that in the performance of the work for which this permit is issued,I shalt employ pe 1 <br /> tion laws of CaVornia." <br /> The applicant must call for all require inspections. Complete drawing an reverse side. <br /> Title: Date: 1 O T <br /> Signed <br /> FOR DEPARTMENT USE ONLY /� p <br /> Date Area <br /> XApplication Accepted by <br /> k <br /> Date <br /> Pit or Grout Inspection by Da e <br /> Final Inspection by <br /> Additional Comments: <br /> ❑ Stk 466-Ml D Lodi 3 -3621 ❑ Manteca 823-7104 [3 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 /> CK* RECEIVED BY DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> ' <br /> -�-c <br /> e►+,a-ze 1pINFO bEv.ioreal <br />