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%-{ <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR .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 r <br /> Local Health District. <br /> yJob.Address 3 �l City c-K `/)Lot Size PM f <br /> 1 -L `-F� Phone q6 3` U-7 / <br /> Owner's Name l Address - - € <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ° <br /> DISTANCE TO NEAREST: SEPTIC TANK EWER LINES DISPOSAL FLD. PROP. LINE <br /> • FOUNDATION AGR LTURE WELL OTHER WELL PITS/SUMPS <br /> F INTENDED USE TYPE OF WELL PROBLEM AREA ONSTRUC ON SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca "+ Dia. f II Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy /Material <br /> e asing Specifications <br /> FI Public 71 Other fi {_"1 Deltaof G t Seal Type of Grout <br /> I I Irrigation --Approx. Depth i I Easterne Seal In Red b <br /> Repair Work Done ❑ Type of Pump H.P. tate Work Done <br /> Well Destruction ❑ Well Diameter! Setop 501 �} <br /> Depth I Filler Material (Below 50'1 (- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 . REPAIRIADDITION l-1„-DESTRUCTIO (No septic system permitted if public sewer is <br /> ., available within 200 feet-1 € <br /> Installation will serve: Residence Commercial_ Other , <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feel:'- Water table depth <br /> SEPTIC TANK ❑ Type/Mfg hilpa i I No. Compartments ;l <br /> PKG. TREATMENT PLT. Cl '- Method of Disposal <br /> Distance to near y�yI }fi``r �y n _ Property Line <br /> I ,I I1 I� i�Er�+4xff.e - <br /> ed of ins-l-eted <br /> LEACHING LINE ❑ No. & Length X11A Total length/size <br /> FILTER BED ❑ Distance to nearest' r,[1 o lvIsion Property Line - <br /> SEEPAGE PITS I I 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 t6-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�oalll 11 required inspections. Complete drawing on reverse side. I <br /> Signed X `4rF � Title': Date: 5 3 <br /> F DEP,4RTMENT USI` ONLY <br /> Application Accepted by _ Pate —� y Area L <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 -835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2019, Stk., CA 95201 <br /> ,g - <br /> FEE MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> .-EH 13.24IREV.s/N_51 �\ r � <br /> EH 14-28 J <br />