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APPLICATION FOR PERMIT r--- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t 1601 E. HAZE T ON AVE., STOCKTON, CA ' <br /> Telephone (209) 466-6781. <br /> PERMIT EXPIRES T YEAR FROM DATE ISSUED <br /> f" (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 /> 9/b S 1 1S <br /> Job Address City_ 'Lot Size PM <br /> Owner's Name Address ' ' , r !�' Pk16ne (�� — z'f <br /> Pk�6n <br /> Contractor IF � <br /> Ci ense o: Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM 'R R° ❑ OTHER ❑ <br /> DISTANCE T0;NEAREST: SEPTIC—TANK-,µ-.--.-- SEWER LINES . } { DISPOSAL,FLD. PROP. LINE I <br /> FOUNDATION AGRICULTURE L OTHER WELL PITS/SUMPS _ <br /> INTENDED USE ;TYPE OF WELL, , PROBLEM AREA TRUCTION SPECIFICATIONS ' t <br /> t <br /> ❑ Industrial ❑ Open Bott6m, .❑ Manteca Dia. f Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Packf Ll Tracy Typ of Casing Specificationsi r <br /> f'l Public ❑ Other r.� Cl Delta Dep h of Grout Sea! Type of Grout xJ <br /> I Irrigation Approx.,Depth I I Easter Surf ce Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ # <br /> Well Destruction ❑ Well Diameter sealing Material {top 50'1 <br /> Depth Filler Material (Below 501 t <br /> TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I I DEST UC ON I I { o septic system permitted if public sewer is <br /> ailable within 200 feet.) <br /> Installation will serve: Residence=` Commetciel 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 ❑ t Type'/Mig '6 Capacity No. Compartments <br /> PKG. TREATMENT PLT. Q # 1 Methodof Dispo ! <br /> i Distance to nearest: s i Well Foundation Property.Line C1 <br /> LEACHING LINE ❑ No.-&_Length-of lines T ta! length/size <br /> FILTER BED , ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size ` tuber <br /> SUMPS ❑ Distance to nearest: FWeI! youndation Q Property Line ` <br /> DISPOSAL PONDS ❑ 'rI t 4- <br /> I <br /> I hereby certify that I have prepared this application and that the work will be done i accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of`the San Joaquin Local Health Di1trict. w' <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 F <br /> certifies the following: "I certify that in the performance.-of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant ust call,f Freqyire n§pections.-,Complate drawing on reverse side. <br /> Signed _ Title: <br /> _ Date: <br /> r> FOR PARXMENT USE ONLY <br /> A Itcation Accepted by a Date <br /> Pit. <br /> out inspection b ' t �r•' 3�-tet ! d S <br /> Dat Final Inspection b <br /> Additional Comments: s t <br /> ❑ Stk 466-$781 ❑Lodi 369-362f,E ❑Manteca 823-7104 ❑ Tracy 835-6385 � <br /> Applicant - Return all copil"to:Envirpvental Health-Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,,Stk., CA 95201 <br /> IEEECK 9 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH "FR=�CEIVEDBY DATE PERMIT NO. <br /> +.EH 13-24(REV. /n5Y <br />