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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON 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 /> .sem <br /> Job Address -`— /2 zz_ Cit " � `� Lot Size 46 °��--� -- PM <br /> 1 / O�yte�G <br /> Owner's Name Address Y/ ( "`� �1 - <br /> Phone <br /> Contractor's Names License No. <br /> Z � Phone <br /> TYPE OF WELL/PUMP: N WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM-REPAIR ❑. - OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANKt SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION I AGRICULTURE WELL 'OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom= -- --.I]-Manteca -Dia. of Well Excavation Dia.-of Well Casing <br /> ❑-Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Y Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal s-" '-Type of Grout d <br /> ❑ Irrigation ---Approx. Depth L1,Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> t a <br /> Well Destruction ❑ Wel] Diameter Sealing Material {top 561 V <br /> Y Depth Filler Material iBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑- DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) ` <br /> Installation will serve: Residence Commercial_ Other` � t+' a <br /> r <br /> Number of living units: / Number of bedrooms <br /> Character of soil to a depth of 3 feet: �.; &.d � � Water table depth a <br /> SEPTIC TANK I�Type/Mfg 6212 L— _ �✓szscp� Capacity e2, '_ No. Compartments <br /> PKG, TREATMENT PLT. El 1 Method of Disposal <br /> Distance to nearest: Well 0 Foundation Property Line <br /> I <br /> LEACHING LINE ff" No. & Length of lines Total length/size _ <br /> FILTER BED ❑ Distance t earesV Well Foundation Property Line S <br /> SEEPAGE PITS 11 Depth ���f� Size �Lr Number <br /> SUMPS ❑ Distance to nearest: Well T—Foundation f'�= Property Line <br /> �4 <br /> DISPOSAL PONDS ❑ <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 District. <br /> Home owner or licensed agent's signatureIcertifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <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 permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must-call-for all required in ctions. Complete drawing on reverse side. <br /> ZIU <br /> Signed r it A �.. Title: ' Date: <br /> FOR DEPARTMENT USE ONLY <br /> r� <br /> P <br /> Accepted by Date Area <br /> Pit r Grout Inspection by <br /> Date�Y Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 RECEIVED BY DATE PERMIT A0. <br /> INFO CASH <br /> + EH 1324(REV.10/831 Li-S <br />' EH 1428[ <br />