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5 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT I <br /> 1601 E. HAZELTON AVE., STOCKTON, CA l <br /> Telephone (209) 466-6781 <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 /> Job Addres ;&5 —�—�� City Lot Siz,,/Z= PM } <br /> Owner's Name <br /> Address ! ,, L Phon <br /> 1 WA � <br /> Contract Addres35X/y` ' U4j - Licks, No. Ph on <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES )ISP FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL THER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONS TION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca ra. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack— ❑ Tracy Type of Casing Specifications <br /> l`l Public ❑ Other { ❑ a Depth of Grout Seal Type of Grout <br /> I I Irrigation _.-Approx. Depth i Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material atop 501 <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Res ence Commercial er <br /> Number of living unite Number of badroom � y <br /> Character of soil to a depth of 3 feet: 1714/1/1 1 Water table depth.._..-..� <br /> SEPTIC TANKQLiS'� ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> r <br /> LEACHING LINE No. & Length of lines Total length/size J 0 <br /> FILTER BED ❑ Distance to nearest: Well FoundationProperty Line <br /> SEEPAGE PITS C I Depth Size Number <br /> SUMPS >-�pistance to nearest: Well�r�! Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certity.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 regulatjons 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 subcontracting 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 i spect ns. Complet drawing rse side. <br /> Signed L Title: . Date:25- <br /> 3. <br /> FOR DEPART NT USE ONLY ` <br /> Application Accepted by Date �� /_� Z !Area <br /> rG out'Irgs ction by -/I- Date Final nspection by; � �/`/ Date <br /> Additional Comments: D <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 /> 1 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PER IT'N0. <br /> INFO +^/ CASH <br /> r EH13-24(REV.1/95) <br /> EH N-2a !!! LLLJJI <br />