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4 APPLICATIOWFOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT o <br /> 1601 E. HAZELTON AVE.,:STOCKTON, CA <br /> Telephone (209) 466-6781 E �,•; , <br /> I. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED w <br /> s* <br /> # s (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,art�Regulations San Joaquin r <br /> Local Health District. . <br /> city / �' Lot Size <br /> Job Address PM <br /> a <br /> r ! _ Phone <br /> Owner's Name _ T ' Address <br /> License No. <br /> Contractor , <br /> TYPE OF WELLIPUMP: NEVI!-WELL LJ " .1,I WELL REPLACEMENT 11 DESTRUCTION El <br /> i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER t I <br /> DISTANCE TO NE RES PTIC TANK SEWER LINES <br /> D15P PROP. LINE <br /> t FOUND AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USETYPE OF WELL EM AR NSTRUCTION SPEC IFIOATIONS y <br /> ❑ Open Bottom ❑ M a ia. of Well Excavation'• Dia.of Well Casing <br /> ❑ Industrial P 1 4! Specifications f <br /> ❑ Domestic/Private ❑ Gravel Pack Tracy Type a <br /> ❑ Public 1 ❑ Other <br /> ❑ pelta Depth of Grout Seal Type'of Grout <br /> ❑ Irrigation pprox. Depth ❑ Eastern Surface Seal Installed by <br /> I H p i State Work Done <br /> Repair Work Done 4 Type of Pump ; <br /> Well Destruc on i ❑ Well Diameter Sealing Mateliial (top 1501 i <br /> Depth Filler 11Aaterial.(Belowi50'i= <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION rREPAIR/ADDITION,❑ DESTRUCTION ❑ aNailabperwithin e20permitted <br /> f etitted if public sewer is <br /> Installation will serve: Residence Commercial Y ther x:► , $$ <br /> Number of living units: Number of bedrooms <br /> . ., - . ;` ate'r.tabid depth <br /> { Character;of-soil to a depth'of 3 feet: 4# N WNo. Compartments <br /> f ` .�i T C, <br /> SEPTICTANK O Type/Mfg <br /> qqI PKG. TREATMENT PLT. ❑ l j Method of Disposal <br /> t 1 i r ? a« �.N< 6 Property Line <br /> Distance to nearest:, Well�' .'Foundation, . <br /> ��/ • Total length/size r ' <br /> LEACHING LINE k N0• & Length of lines. r I a <br /> ' ' '`1. - I.-,\ da �- Foundation' U� Property Line* i <br /> [ FILTER BED Distance to nearest: WeII G� -` l <br /> Number <br /> SEEPAGE PITS Both i Size <br /> SUMPS istance to nearest: Well 4undation Property Line d <br /> F i 7 <br /> signature <br /> DISPOSAL PONDS <br /> application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have:pre .red this app �` <br /> rules and regulations of the San Joaquin Local Health District. 1��, i. <br /> Home owner or licensed agent's signature certifies the following:"I certif}f'that m the'{ierfoimance of the work for which this permit is issued, l shall not <br /> employ any person irin <br /> n such manner as to become subject to.workman's corapensation laws of California.';,Coiltracersonsrsub'ect t wg or o <br /> rkman's oompensa <br /> certifies the following: "I certify that in,the performance of the work for whch this permit is issued, l shall employ p 1 <br /> t tion laws of California." <br /> The applicant must call for all quir inspections. Complete drawing on•reverse <br /> a i <br /> r ! <br /> Title: —��°'�``�� 4�, Date: <br /> Signed ; -:_ 't i t <br /> R DEPARTMENT USE ONLY t <br /> Application Accepted by Date r <br /> I Pit or Grout Inspection by Date <br /> Inspection by Date_ <br /> Additional Comments: t` <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385Ave., P.O.Applicant- Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton ., P. Box 2009, Stk., CA 95201 s <br /> t <br /> CK <br /> FEE c RECEIVED BY u�DATE <br /> PERMIT Nt). <br /> 1. INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> + EH 13-241REV.1J05 —7<:> <br /> "�� <br /> EH 1426 7 `; <br />