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^ r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICTS <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE .ISSUED �y;a. � 3 <br /> (Complete in Triplicate? •. <br /> .. L HEALTH <br /> ped,' is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herejn„�esct ran <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules an a i en Joaquin <br /> Local Health District. <br /> Job Address <br /> 0 p + Ciry Lot Size PM <br /> ;i <br /> /��,I � Phone! ”�•�1 <br /> Owner's Name Address/_ 4 <br /> k1. <br /> Contractor <br /> Address G License No1_( 23 2 3 Phone 6 61� <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ (\ <br /> PUMP INSTALLATION.91- SYSTEM REPAIR ❑ OTHER ❑ V <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll Industrial ❑ Open Bottbm ❑ Manteca Dia. of Well Excavation pie. of Well Casing <br /> T of.Casin Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy <br /> Type g Type of Grout <br /> ❑ Public 17 Other <br /> 1 ❑ Delta 1 `,. Depth of Grout Seal i <br /> ❑ Irrigation ---Approx. Depth ❑_Eastern = urfSeaIJnstalledhby� — <br /> Repair Work Done 2, Type of Pump H.P. — ;r I State Work Done j <br /> Well Destruction ❑ Well Diameter Sealing Material (top•I <br />` Depth Filler Material (Below 50'1 i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ allo bpe+wi hit system permitted if public sewer is i <br /> Installation will serve: Residence— Commercial_ Other_ <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 TAMC F1 Type/Mfg F t Capacity No. Compartments <br /> - j Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> ITotal-length/size <br /> LEACHING LINE ❑ No. & Length of lines , <br /> FILTER BED ❑ Distancepto nearest: Well - -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 parsons subject to workman's compensa- <br /> tion laws of California." <br /> k The applicant st all for all required inspections. Complete drawing on reverse side. / <br /> i <br /> title: k _ Date: <br /> Signed / <br /> R DEPARTMENT USE ONLY / <br /> Date / r — Area <br /> Application Accepted by <br /> Date Final Inspection by_� 't" �� Date <br /> Pit or Grout Inspection by _ <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy- 835-6385 <br /> f Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CK# RECEIVED BY DATE -PERMITNO. <br /> FEE AMOUNT DUE AMOUNT REMITTED GASH <br /> } 1NF0 <br /> a EH13-24 MEV. <br /> EH 14-28 <br />