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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT . <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> r PERMIT. EXPIRES 1-YEAR FROM DATE ISSUED <br /> j� (Complete .in Triplicate) ' <br /> i <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 /> j S City -- Lot Size 130 c e PM <br /> Job Address <br /> Owner's Name +fl <br /> Address Phone <br /> w ' <br /> 00, <br /> License No. y-Phone`1 <br /> Contractor Address <br /> WELL REPLACEMENT DESTRUCTION 0 ' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ SYSTEM REPAIR ❑ [rNp OTHER ❑ <br /> PUMP INSTALL4TION /�, � <br /> SEWER LINES DI*S� FLD.-7D PROP. LINE Z� <br /> DISTANCE TO NEAREST: SEPTIC TANK _.G0 — PROP. LINE <br /> FOUNDATION _ UMPS <br /> AGRICULTURE WELL OTHER WELL— 7A <br /> USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,r <br /> Dia. of Well Casing <br /> F] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ; <br /> � <br /> Type of Casin �d G _ Specifications l�O Domestic/Private Grave) Pack ❑ Tracy yp g� Type of Grout <br /> F1 Public - Other _T ❑ Delta Depth of Grout Seal _�J�l� <br /> urface Seal Installed by '� t <br /> I i Irrigation --Approx.' Depth l I Eastern r <br /> Repair Work Done ❑ Type of Pump 15"P" H P State Work Done <br /> Well <br /> i <br /> Well Destruction ❑ Well Diameter Sealing Material {top 50'i — <br /> Depth 1 Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTAL l;i REPAIR/ADDITION l I DESTRUCTION I I (No septicailable sy t m rented if public sewer is <br /> Installation will serve: Residence '_LI Commercial, Other <br /> i Number ofliving units: Number of bedrooms r w <br /> s-Water table depth <br /> Character of soil to a depth of 3 feet: <br /> Capacity -{ No. Compartments, <br /> SEPTIC TANK ❑ Type/Mfg .. � Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> s <br /> Distance to nearest: Well i "`Foundation"" - .Property.Line <br /> i ° Total length/size I <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED ❑ Distance to nearest: Well Foundation_ �_Property Line <br /> SEEPAGE PITS I I Depth <br /> Size a `- NunrI " 'x <br /> SUMPS Ll Distance Eo nearest: Well Foundation Property,Line ] <br /> DISPOSAL PONDS ❑ <br /> i I hereby certify that I have prepared this application and that the work will be donaccordance withSan Joaquin ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health <br /> District. <br /> Home owner or licensed agent's signa[ure certifies 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 /> I tion laws of California." l S <br /> The applicant must call f r all required inspectio Co plete drawing on reverse side. <br /> Title: Data: f <br /> Signed X 'tl <br /> i FOR DEPARTMENT U ONLY <br /> Date + U Area <br /> Application Accepted by , _ h <br /> Date Finalalnspection by Date 0 <br /> Pit or Grou Inspection by • <br /> I Additional Comments: <br /> ❑ Stk 466-6781 ❑ L i 369-3621 ❑ Manteca 823-71 r3 Tracy 5-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> C RECEIVED BY DATE �11EPERM2111")NIJ,FEE AMOUNT DUE AMOUNT REMITTED C <br /> INFO �1 <br /> EH t4-2a l <br />