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APPLICATION FOR PERMIT '^ <br /> SAN JOAQUIN LOCAL.HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466_6781 <br /> PERMIT EXPIRES i 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 ell/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. n <br /> �] Q �j+{-LV.t4A� <br /> Job Address D ! <br /> c City Lot Size �f .PM <br /> Owner's Name Address i ! — 3sU <br /> Phone <br /> ContractorO <br /> Address }License No. Phone <br /> TYPE OF WELL/PUMP: N WELL O WELL REPLACEMENT ❑ DESTRUCTION <br /> Li <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR '3 �' OTHER ❑ y <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER-LINES{ DISPOSAL FLD. PROP.'LINE <br /> ++ FOUNDATIONAGRICULTURE'WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE,0`F' WELL PROBLEM AREA CONSTROCTION SPECIFICATIONS <br /> ❑ Industrial �1. ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private ' ❑'Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Sealq <br /> '❑ Irrigation ' -Type of Grout <br /> —�pf1� <br /> prox. Depth ❑ Eastern Surface Seat Installed by <br /> Repair Work Done ❑ -./Type of Pump H.P. State Work Done <br /> Well Destruction ! ❑�.' Well Diameter Sealing Material (t ` <br /> Depth Filler Material (1391;z) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAI /"ADDITION DESTRUCTION ❑ (No se tia s <br /> r p ystem permitted if public sewer is - <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial Other 1 <br /> }k Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth j <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ' <br /> PKG!�TREATMENT,-PLT. ❑�AP ,' Method of Disposal <br /> Distance to nearest:- Well Foundation Property Line # <br /> LEACHING LIN ❑ No. & Length of lines <br /> Total length/size 1 0l } <br /> FILTER BED ❑ Distance to nearest: Well <br /> Foundation. Property Line <br /> EEE AGE PIT EJ Depth <br /> Number <br /> SUMPS ❑ Distance to nearest: Well 0 Foundation 6a Property Linej <br /> DISPOSAL PONDS ❑ g i <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 SanJoaquin 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 became subject to workman's compensation laws of California."Contractors 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 m st c or a equire tons. Compl a rewing en �side. <br /> 'Signed- - - - - �' - _ .- _­ '/ ` <br /> Title: Date- <br /> FOR-DEPARTMENT <br /> ate:FOR-DEPARTMENT USE ONLY <br /> Application Accepted by Dat"76 Area ' <br /> x ` <br /> Pit Grout Inspection by Date Final Inspection by r Date G <br /> Additional Comments; . <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 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 /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO RECEIVED BY <br /> CASH DATE PERMIT`NO. <br /> + EH 13-24(HEV.i/as) <br /> j 0 <br /> EH 14-29 <br />