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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> /Application <br /> 1601 E. HAZETON AVE:, STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> ereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> ance 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 /> isttrriicct. <br /> Job Address �� �/' A �� ��f / t f��✓ - _ City Lot SizB; a57X <br /> 12e k! PM <br /> Owner's Name 4",&J` Address / 2 <br /> y 4jr <br /> C�ritracto��. – +�= Addres`s '.-� �7 Y70 � License[Vo. t ' v"Prone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION A---' SYSTEM REPAIR D OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE /dD <br /> FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS if <br /> ❑ Ind6strial pen Bottom ❑,Manteca Dia, of Well Excavation Dia. of Well Casing <br /> K -. <br /> omestic/Private ❑ Gra%6 Pack El'Tracy Type of Casings d� Specifications <br /> i 1"��I,rblic ❑.Other ❑ Delta Depth of Grout Seal � f Type it rout �L <br /> I I Irrigation , —.Approx. Depth I ] Eastern Surface Seal Installed by _ <br /> Repair Work Hone" '%❑ Type of Pump r H.P. State Work Done <br /> g <br /> Well Destruction ❑'N. Well Diameter Sealing Material (top 501 W <br /> f Ddoth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEft INSTALLATION 11 REPAIR/ADDITION 1 1 DESTRUCTION I i fNo septic system permitted if public sewevis O <br /> available within 200 feet.) <br /> Installation will serve: "flesidence, Commercial= .Other s� <br /> Number of living units: Nunober 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 /> Lt , <br /> LEACHING LINE ❑ No. & Length of lines _ Total length/size <br /> t FILTER BED ❑ Distance to nearest: Wellti Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size _ Number <br /> SUMPS L� Distance to nearest: Well Foundation Property Line <br /> f DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the wa.k 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 shalt not <br /> employ any person in such manner as to become subject to workman's•compensation laws of California."Contractors hiring or sub-contracting signature <br /> j,- 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 inspect! ns. Complete drawing oh reverse side. <br /> Signed X Title: 2!n: Date: f <br /> FOR DEPARTMENT USE ONLY l b <br /> Application Accepted4yjga� <br /> Date O Area Q <br /> t Pit or Grout Inspectio It, `!"Final;Inspection by t "L Date [ 7 <br /> 11114' 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 2009, Stk., CA 95201 <br /> I <br /> FEE AMOUNT DUE AMOUNT REMITTED CK 0 RECEIVEDBY DATE PERMIT'NO. <br /> INFO CASH <br /> , Eli13-24(REV.,i/s 51 '5 <br /> EH 14-28 <br />