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c <br /> S✓ APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE.; STOCKTON, CA <br /> 'T, Telephone (200) 466-6781 <br /> ( <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> � V_A SA Q- ` (Complete in Triplicate) <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 /> Loco! Health District. <br /> !1(o .¢�did"sr Gak� �G�f.d <br /> Job Address K-e r -tip .�ys_O`f o 0 City YO Lot Size �`� 7 pt PIN <br /> Owner's Name +�`� Address f Phone <br /> - 11 <br /> Contractor • Address 0r $ r� g License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST; SEPTIC TANK Vah$! SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE-OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAATJfy$ y �� <br /> ❑ industrial ❑ Open Bottom )(Manteca Dia. of Well Excavati Dia. of Well Casing �(J <br /> ❑ Domestic/Private Pack ElTracy Type of Casing ESpecifications <br /> E] Public El Other El Delta Depth of Grout Seal �d pe CQ <br /> "Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.H.P. State Workfe_ *J <br /> Well Destruction E) Well Diameter-•--yam Sealing Material {top 50'I (� <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> "k LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Wall Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 <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 />! 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." <br /> The applicant all for II r d inspections. Complete drawing on reve side. <br /> Signed Title: Date: �-1 u <br /> FOR DEPARTMENT USE ONLY <br /> s <br /> Application Accepted by f Date l`" Area 6S <br /> Pit or Grout Inspection by Date + Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca '823-7104 ❑ Tracy 83x5 6305 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED LCK RECEIVED BY DATE PERMIT`NO. <br /> INFO j� CASH <br /> + EH 13-241REV.1/e 5) �[/ QA.. f//^ < 9 7� <br /> EH 1428 < 42 <br />