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APPLICATION FOR PERMIT <br /> '"Ll <br /> .z SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i <br /> -- 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> <, �A PERMIT EXPIRES TYEAR 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 /> City <br /> Lot Size PM <br /> Joh Address <br /> Phone <br /> a'✓,rte � <br /> Owner's Name ? i <br /> y <br /> ddress <br /> License No. Phone <br /> Contractor DESTRUCTION <br /> NE WELL ❑ WELL REPLACEMENT <br /> TYPE OF WELLIPUMP: SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ <br /> SEWER LINES —_-- DISPOSAL{FLD. PROP. LINE. <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL•'° OTHER WELL PITSISUMPS <br /> FOUNDATION <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> [J Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Specifications <br /> Type of Casing <br /> ❑ DOmesticIPrlvate L1 Gravel Pack ❑ Tracy Depth of Grout Seal Type of Grout — <br /> ❑ Public 171 Other 1-1 Delta p <br /> �ApproxDepth I I Easter Surface Seal Installed by <br /> 7 <br /> t I Irrigation - _ r H.P. State Work Done_ <br /> Repair Work Done C1 Type of Pump <br /> ,¢ <br /> ' � Sealing-Material Itop-50'! <br /> Well Destruction ❑ Well Diameter <br /> Depth Filler Material (Below 50'I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAtRIADDITIONYI 1 PEST�U TION t l atvailable rwthin 200 feet.)permittedc system e public sewer is <br /> Installation will serve R sidence! Commercial t Other <br /> Number of living units: Number of bedrooms_— 3 Water table depth <br /> Character_ of soil to a depth of 3 feet: , No. Compartments <br /> ❑ Type/Mf ° ! Capacity 4 <br /> SEPTIC TANK g _ Method of Dis osat <br /> f <br /> PKG. TREATMENT PLT. ❑ <br /> tFoundation Progerty Line <br /> (� Distance to nearest: Well — <br /> Total length/size <br /> LEACHING LINE' ❑ No. & Length of lines <br /> ❑ Distance to nearest: WellProperty Line- Foundation -�— <br /> E' FILTER BED ;r i <br /> k Number <br /> EEPAGE PI f I Depth{, --Size -. <br /> Foundation�r Property Line <br /> S'OMPS ❑ Distance to nearest: Well��_.. � <br /> DISPOSAL PONDS ❑ <br /> ate laws, and <br /> { hereby certify that I have prepared this application and that the work will be done in accordance with San.Joaquin county ordinances, st <br /> rules and regulations of the San Joaquin Local Health District. <br /> 4 signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's sign <br /> employ any person in such manner n to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that iri the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa <br /> l tion laws of California." t . r � <br /> ( <br /> The applicantmus 11 far all re 'e inspections. mplete drawing on rse side [LJ (XJ <br /> Date: <br /> Title: <br /> Signed X f <br /> f FOR DEPARTMENT USE ONLY q 17 / <br /> t , _Date a 0 Area l r <br /> Application Accepted by t t ! �� <br /> [ .k� <br /> Pit or Grout Inspection by <br /> Date Final Inspec4n by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑,Manteca 823-7104 ❑ Tracy 838.-6386 <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 /> INFO <br /> �J tOOLd�/ TCJ <br /> r.EH13-24lREV.t/rs51 / <br /> EH 14-28 <br />