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{ <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br />[ Telephone (209) 465-6781 <br /> PERMIT EXPIRES 'i YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> f Application is llmade 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. 2-2-6 d '''� <br /> �A City ACLot Size APhr CpM <br /> Job Address <br /> Owner's Named Adress `'TAdW phone <br /> Contractor Gl <br /> Address R License N 3 Phon 'a 7T <br /> TYPE -OF """""""NEW-WELL— WEL-L-REP LACE MENT '--^ - DESTRUC-TION-H <br /> PUMP INSTALLATION SYSTEM llEl OTHER El <br /> f <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK . SEWER LINES �J _ <br /> .FOUNDATION = 6 1-� AGRICULTURE WELL _ OTHER WELL PITS/SUMPS <br /> t <br /> INTENDED USETYPE OF WELL ,PROBLEM AREA CONSTRUCTION SPECIFIGATIO S r <br /> I <br /> ��_- <br /> ❑ Industrial sr It Open-Bottom ❑ Manteda` Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private }Gravel Pack `❑ Tracy t Type of Casing _e_-e - Specifications <br /> f"1 Public <br /> 1 3 Other— C1 Delta Depth of Grout Seal Type f <br /> p I i Irrigation !?_'9'_0--Approx. DepthEastern Su ace Seal installed by r f1 <br /> l Repair Work Done ❑ Type of Pump H.P.ILI —7 State Work Done vh <br /> I V <br /> Well pestructiori x�❑ . VVeI["Diameter f+ Sealing Material (top 50'1 rF <br /> Depth.f^ <br /> L Filler Material (Below 50') �l <br /> TYPE OF SEPTIC WORK: NEW 1148TALL ATION t] REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public{ewer is <br /> available within 200 feet.) <br /> Installation will serve:; Residence— Commercial's Other <br /> c <br /> Number of living units:-° Number of bedrooms <br /> � T' ` Water table depth <br /> Character of soil to a depth of 3 feet: <br /> ° ' Capacii No. Compartments 1 <br /> • SEPTIC TANK ❑ Type/Mfg y <br /> PKG. TREATMENT PLT. 0Method of Disposal ) /� <br /> € i - <br /> Distance-to nearest:., Well Foundation Property Line �-`y , _ •.-.- <br /> kA <br /> LEACHING LINE ❑ ll Length-of lines ❑eng 4 _ <br /> FILTER BED ❑ Distance to neares. WeH Foundation Property Line ` <br /> 1 SEEPAGE PITS I ! depth Size — Number ' <br /> Pro ert Line <br /> SUMPS L] Distance to near`est:•� Well Foundation P Y <br /> k DISPOSAL PONDS 71 � <br /> I 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 C r' <br /> tttt rules and regulations of the San Joaquin Local Health District. 4 <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the$erformance of the work for which this permit is issued, i shall not <br /> a y 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 /> j certifies the following:."I,certify:tharin•the manc <br /> perfore of the work for which this permit is issued, I shall employ persons subject to workman's compensa <br /> t tion laws of California." f <br /> j The applicant mu t call for all required'i spections. Complete drawing on reverse side <br /> 1 Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> 2ff <br /> € 'Applicatio Accepted by Date Area <br /> Pit or ro Inspection by Date +' final Inspection by• Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 835-6385 <br /> t Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> k FEEtAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT•NO. <br /> INFO l� <br /> ..EH 13.24 1AM I 51 O $, 00 ���Z•=t rte• <br /> EH 14-26 -[ <br />