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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEARFROM DATE ISSUED . <br /> {Complete in Triplicate} ; L •��= <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 Joaquinr <br /> Local Health District..X <br /> J . . v/ Ci Lot Size �' " PM <br /> Job Address a ( n ty g y p <br /> Phone J 0 58 <br /> Owner's Name <br /> Contractor's Name .— L an Phone <br /> i TYPE OF WELL/PUMP: NEW WELL ❑ /WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE a <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> E] Domes tic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth'❑ Eastern - Surface Seal Installed by <br /> Repair Work Done 17Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Stop 501 <br /> t Depth Filler Material Vel2w 50'1 <br /> Ik TYPE OF:SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION O INo septic system permitted if public sewer is - <br /> E available within 200 feet.l <br /> Installation will serve: Residence_ Commercial— Other <br /> " Number of living units: Number of bedrooms h,�C�s���'W <br /> I Character of soil to a depth of 3 feet ater table depth <br /> SEPTIC TANK ❑ Type/Mfg / Capacity _S No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal , <br /> Distance to nearest: Well Foundation Property Line 4 <br /> ' U T4tal length/size Ak <br /> LEACHING LINE No. & Length of lines <br /> FILTER BED CIDistance to nearest: elIZa0 Foundation �0 Property Line S <br /> SEEPAGE PITS Depth Size 3'. r uber <br /> SUMPS ❑�'Distance to nearest: WeII�iv t <br /> — Foundation � m� Property Line . 1 <br /> i <br /> DISPOSAL PONDS ❑ t <br /> f 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: "Im�certify'fhat 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 workan 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." N <br /> k The applicant must call for ail required inspections. Co plate drawing ori reverse side.t t <br /> s, <br /> Signed Title: Date: <br /> FOR DE 'ARTMENT USE ONLY—' <br /> rea o <br /> (j� <br /> Application Accepted by Date A <br /> p <br /> . IDate <br /> Pit or Grout Inspection by Date ti -Final Inspection by Die <br /> . 0 A t _. - �Y <br /> Additional.Comments: <br /> ❑ Stk 466-6781 Lodi 319-3621 ❑ Manteca 823-7104 ❑ Tracy 835-M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,P.O. Box 2009, Stk., CA 95201 , <br /> FEE AMOUNT.DUE AMOUNT REMITTED C K RECEIVED BY DATE PERMIT'N0. <br /> INFO }} <br /> +EH1324iAEH.10/531 _I.. �1�. �]a ���� �" 5�43/C� WA 1-4- _ <br /> EH 14-26 <br />