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I' <br /> APPLICATION FOR PERMIT <br /> - SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVEU <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 ,U L 12 19911 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH <br /> �° (Complete in Triplicate) T <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work <br /> FgMJ}-Je5ERV1g�li ation is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1$62 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> City Lot Size PM <br /> Job Address / <br /> Owner's Name <br /> f Address Phone <br /> 1 f <br /> T <br /> Contractor ; <br /> dress License Nv. 4� Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ <br /> �-�--PUMP:INSTALLATION-❑--------- �d--- SY-STEM.REPAI OTHER ❑ <br /> _. ,a•: <br /> —DISTANCE TO NEAREST:"SEPTIC TANK SEINER LINES-`' DISPOSACTFLD:�• PROP- LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL ' PITSISUMPS <br /> INTENDED USE i TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ><romestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications , <br /> f" Public FI Other <br /> ! Depth of Grout Seal Type of Grout <br /> I I Irrigation —.Approx. Depth l 1 Easterrm f Surface Seal Installed by <br /> f I State Work Done <br /> Repair Work Done �❑ Type of Pump# H.P. ��� <br /> Well Destruction' f❑ Well Diameter Material (top 50' <br /> t Depth Filler Material (Below 501 — <br /> fTYPE OF SEPTIC WORK: NEW INSTALLATION 11 RE=PAIWADOITION t I DESTRUCTION l I (No septic system permitted if public sewer is ! <br /> available within 200 feet.) <br /> 1 Installation will serve: Residence_ Commercial_ Other <br /> r <br /> I Number of living units: __Number ofof bedrooms _ - <br /> I Charac erof soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK t ❑ Type/Mfg I Capacity _ No. Compartments <br /> `PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> F Distance to nearest: Well Foundation Property Line~- <br />' <br /> f ! <br /> LEACHING LINE ❑ No. & Length of lines Total length/size"� ` <br /> FILTER eED7 ❑ Distance to nearest:. Well Foundation Property Line <br />` Size Number <br /> _.SEEPAGE`PITS I I Depth — <br /> w SUMPS - istance-to-nearest :Well - Fou 0n ('Prop Pty'Line - <br /> DISPOSA•L',RONDS ❑ <br /> { hereby certify that I have prepared this application and that the work will be done in accordance with,San Joaquin county'ordinances, stateaaws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner•or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this-permit is issued, I shall not <br /> subject to workman's compensation laws of California."Contractor's hiring or `sub-contracting signature <br /> employ any pars 'ri such manner as to becomes ) � � <br /> certifies the foil win "I certify that in the performance of ttie'work for which this permit is issued, I shall employ persons subject to workman's compens� <br /> tion laws o fo ia." E <br /> :The applica st call fpr req ire inspecti Complete drawingPRTTM <br /> v r e side. z <br /> Date: <br /> I <br /> Signed X Title: <br /> g l �� <br /> s FO��DEP NT USE ONLY <br /> �; Date � Area. 2,., <br /> Application Accepted by t <br /> jC <br /> Pit or Grout Inspection by date I Final Inspection b Date7' <br /> iAdditional Comments: ' <br /> l ❑ Stk 466-6781 ❑ Lodi 369-3621 D-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 /> i U <br /> FEEDAMOUNT DUE AMOUNT REINAITTECASH RECEIVED BY DATEPERMIT NO. <br /> INFO <br /> 4 E 13-24(REV.I/N5) LA <br /> cr <br /> ' EH 14 26 <br /> t. <br />