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` l r .4 � i <br /> FS67 <br /> f <br /> t APPLICATION FOR PERMIT <br /> 'i z�° y SAN .�OAQUIN LDCAL HEALTH DISTRICT <br /> 1601 E.'HAZELT ON AVE.,STOCKTON, CA 4r <br /> 209 <br /> Telephone p { } 466-6781 � <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r� <br /> (Complete in Triplicate) s°tiff tU rLf <br /> ilrrl�"A" <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,.appliCeition is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules-end Regtilations,of the"SAn Joaquin <br /> Local Health District. <br /> Joh Address g r <br /> Cit PM <br /> {' 7 l r <br /> Owner's Nammajxl Address —23-7-ST Phone ! [ <br /> Contractor O q-7 nse fVa, Phone <br /> TYPE OF WELL/PUMP: �NEW-WE L :❑ ' WELL REPLACEMENT,❑ , J DESTRUCTION ❑ <br /> PUMP,INS'TALrL 'TION ❑ SYSTEM REPAIR Ell 3 OTHER ❑ <br /> DISTANCE TO NEAREST:-SEPTIC-TANK SEWER LINES DISPOSAL,FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL'S j PITS/SUMPS �} <br /> INTENDED SE�y`� TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j <br /> ❑ Industrial Cl Open Bottom � .� 0 Manteca Dia. of Well Excavation i Dia. of Wel! Casing <br /> • Domestic/Private ❑ Gravel-Pack. _ - ❑ Tracy Type of Casing ! Specifications <br /> ,If-] Public C1 Other r# j!ti.};. Delta Dept o{G;ouI,Seal Type of Grout ] <br /> f I I Irrigation Approx.IDept I astern S al Installed by <br /> 7 Repair Work Done, Re Type of Pump H.P. State Work Donee <br /> t Well Destruction�,i ❑, Well.Diameter^ Sealing Material !top 50'1 ' 1 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I:1 REPAIR/ADDITION I I DESTRUCTION I I Mo septic system permitted it public sewer is i <br /> � available within 200 feet.) <br /> Installation will serve: Residence_' Commercial_ Other fi <br /> Number of living units: Number of bedrooms <br /> t <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg' Capacity_____1_ No. Compartments - <br /> PKG. TREATMENT PLT. ❑ i r Method of Disposal <br /> Distance to nearest: Well Foundation Property Line F <br /> 1 <br /> LEACHING LINE ❑ No. & Length of lines !Total Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i I Depth Size f, Number <br /> SUMPS (_1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I hav is application and that the work will be'done'in accordance with county-ordinances;,state laws, and <br /> rules and regulation the San Joaqu Local Health District. <br /> Home owner or r r sA. agent's signatu certifies the following: "I certify that in.the performance of the work for which this permit is issued, I shall not <br /> employ any pe on in such manner as to ecome subject to workm o pansation laws of California." Contractor's hiring or sub contracting signature <br /> certifies the f owing: "I certify that'in performanc t e f jwwh' h thii4'perm' is issued, I shall employ persons subject to workman's compensation laws ofalifornia."The applicant ust cal!for all re r inspe n o awinrever <br /> Signed X i <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date_ <br /> d �t - Area <br /> Pit or Grout Inspection by Date Final Inspection by � Date ._.Q�` <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 O Tracy 635-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 n <br /> s <br /> FEE <br /> INFO AMOUNT DUE 1 AMOUNT REMITTED CK RECEIVED <br /> CASH BY DATE PERMIT'NO. f <br /> + EH 13-24(riEV.I/n 51 <br />