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APPLICATION FOR PERMIT <br /> - ,AN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 ' <br /> E <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (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 /> Local Health District. <br /> p ! 16M cee,f_ PM <br /> ,A. t 10�7d ��� City Lot Size <br /> Job Address . <br /> C / e Address d 67? l�C—� Phone <br /> Owner's Name z f� ! �r�^'�. <br /> ,t/ Address >or `' License No� n-Phone,•-- `_s <br /> Contractor � <br /> TYPE OF WELL/PUMP: N WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ M444110- <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 17 OTHER <br /> DISPOSAL FLD. P OP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PITS/SUMPS <br /> FOUNDATION <br /> AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> i <br /> 11Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> Type of Casing specifications_-3' <br /> ❑ Domestic/Private Gravel Pack ❑ Tracy Yp g Type of Grout <br /> 1­1 Public FI Other Cl Delta Depth of Grout Seal YP <br /> I i Irrigation -Approx. Depth ! I Eastern Surface Seal installed by <br /> le <br /> - Work- _ r <br /> Repair Work Donees L�7ype of Pump —H-,P - - _._.__.. State Dane <br /> Well Destruction . ❑ Well Diameter - Sealing Material (top 501 <br /> �fyja..7�rerwa LJc6t" Depth Filler-Material (Below 501 <br /> t i No septic system perm7pubIicse,-er ,5 <br /> ATION`I1-REPAIRIADDITION l I DESTRUCTION I P Y <br /> TYPE OF SEPTIC WORK: NEW INSTALL available within 200 feeInstallation will serve: Residence Commercial` OtherNumber of livingunits: _ Number o_f bedrooms ,, ,,.�Character of soil to a depth of 3 feet: Water table deptSEPTiC TANK ❑ Type/Mfg Capacity No: CompartmenPKG. TREATMENT PLT. ❑ <br /> Method of Disposa <br /> _ Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property'Line <br /> SEEPAGE PITS I ) Depth Size, Number t <br /> SUMPS L-I Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS'•`'"-'0 <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. I - <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 must call for all required ins a tions. Complete drawing on reverse/side. � y <br /> 1' Date: - S Al A- <br /> Signed X Title: "^ - <br /> 1 <br /> y I FOR DEPARTMENT USE ONLY <br /> Application Accepted by / <br /> Date Area <br /> Pit or Grout Inspection by Dates f Final Inspection'b ' �� Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ""'O Lodi„369-3621,•, � 0 Manteca, 823.7104 ❑ Tracy 835-6385 <br /> Applicant - Return all'copie�s to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,-CA 95201 <br /> FEE- AMOUNT DUE AM&N'T REMITTED C y--RECEIVED BY DATE :PERMIT'N0, <br /> + EH 13.24IAEV,rin51 ��. - g � <br /> �S` Q <br /> EH 14-28 <br />