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F <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466 67$1 <br /> PERMIT EXPIRES 1 YEAR FROM IRATE ISSUED <br /> (Complete in Triplicate) 'K <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 /> tmade 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. �("T-//3 '.i <br /> City Lot Size �•e��'�� PM <br /> Job Address - <br /> owner's Name +ress Phone <br /> Contractor Address icense No. * Phone <br /> I TYPE OF WELL/PUMP: NEW WELL ❑ -WELL-REP,LACE ENT ❑ DESTRUCTION ❑ <br /> s <br /> PUMP INSTALLATION © ' SYSTEM REPAIR ❑� �'�'""""'"OTWER C]�: <br /> DISTANCE TO NEAREST: SEPTIC TANK LJ SEWERFLINES DISPOSAL FLD. PROP.. LINE <br /> FOUNDATION `AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA4�,f:6-ONS7 LICTiON SPECIFICATIONS <br /> ❑ Industrial El Open Bottom ❑ Manteca DiaAyafyWell Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy,J Type,of Casing Specificaiions 1 <br /> ("1 Public ❑ Other ❑ Delta (De: ptA of Grout Seal Type of Grout _. <br /> I Irrigation —.-Approx. Depth l 1 Ea 4Q a uria a Seal Installed by State Work Work Done <br /> Repair Work Dane ❑ Type of Pump H.P. _ r <br /> Well Destruction ❑ Well Diamet'e'r-% �� " - Sealing MateriaC(top 501) - <br /> 1 Depth' 6L Filler Material i lelow 50 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATI34.1 I RgPAIR/ADDITION DESTRUCTION I I fNo septic system permitted it public sewer is <br /> F. ' available within 200 feet6 <br /> 1 fInstallation will serve: Residence} Commeraa Other r t <br /> Number of living units: Number of bedr oms ,.. <br /> s F ; , •-,- •-.- . Water table de <br /> Character of soil to a depth of 3 feet: l - _ depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments. <br /> I PKG. TREATMENT PLT. ❑ -I j`j Method of Dispos <br /> Distance to nearest: Well�� _5ound"ation M1 Property Line <br /> LEACHING LINE *N & Length of lines ry Total length/size I <br /> FILTEW13ED LT-',.Distance to nearest:—Well FOTffi9ation' Property Line c..[— <br /> SEEPAGE PIT1Depth! I Size G !/ Numbt3r <br /> i SUMPS,11 ,LI Dsfan1ce to nearest: Well _ y'kFoundation f Property Line l <br /> DISPOSAL POAIDS..� ❑ I -- �� + <br /> I hereby`certify thatFiave prepared this application and that the wok will be done in ac ordance with 'bri Joaquin county ordinances, state laws, and <br /> rules and regulations`of the San Joaquin Local Health Dibtrict. � <br /> Home owner or licensed agent's signature certifies the following: "I cert that rn he 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." Cgntractor'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 perspns subiect to workman's compensa- <br /> tion laws of California._-— <br /> Theapplicant c for ail re uired inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Data l Z Area <br /> Pit or Grout Inspection by r Date Final Inspection by Date <br /> Additional Comments: Ah I?sCE 19!W1 j> We— <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-5385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 „hn <br /> INFO <br /> EEE AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. <br /> a.EH13-24(REV:1/KS) ­2^00� <br /> EH 14-26 ° <br />