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{ <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT VE <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA A��] �gO <br /> i Telephone (209) 466-6781 <br /> 1PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH <br /> 11 (Complete in Triplicate) PERMIT/SERVICES 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. I <br /> Job Address �' City Lot Size PM <br /> Owner's Name Address Phone <br /> Gontracto� � Address - Y,License No. � a� Phone�'�" k <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION Y1, SYSTEM REPAIR A- OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE +I <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS -� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> N&omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> FI Public ❑ Other i Cl Delta Depth of Grout Seal Type of Grout ` <br /> I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by <br /> Ir <br /> Repair Work Done 0— Type of Pump'.c-t.-- H.P. f11"'�� State Work Done <br /> r <br /> Well Destruction O Well Diameter l Sealing Material (top 50') <br /> Depth I Filler Material (Below 50'I <br /> - TYPE OF SEPTIC WORK: NEW INSTALLATION I.i REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is r�l� <br /> available within 200 feet.) l <br /> Installation will serve: Residence_ Commercial_ Other �• \ <br /> i <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:ltt- <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments `/1V <br /> PKG. TREATMENT PLT. ❑ f Method of Disposal C^-- <br /> t <br /> Distance to nearest: Well Foundation Property Line 1 <br /> x � <br /> LEACHING LINE [I No. & Length of lines Total lengtrh/size <br /> FILTER SED C] Distance to nearest: Well Foundation Property Line <br /> � J i <br /> SEEPAGE PITS I i Depth 4 Size Number t (' <br /> SUMPS ❑ Distance to`rnearest: Well Foundation Property Line (' <br /> DISPOSAL PONDS. LI 11 <br /> I hereby certify that I have prepared this1application 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 signature certifies the following: "!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." I <br /> The applicant al! for all requirQd i r�spections. Complete drawing on reverse side. <br /> Signed X Title: �� a� Date: <br /> F R D ARTMENT USE ONLY f <br /> Application Accepted by Date Area 2'/t" <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: f <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 /> ® FEECK <br /> INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. <br /> +.EH 1324 1REV.t i H 5) ¢.� <br /> EH 14-28 U % lqo <br />