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�N <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephohe (209) 466-6781 <br /> { PERMIT EXPIRES 9 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 /> P 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 Address / r / City %I Lot Size PM <br /> Owner's Name Address Phone <br /> Contractor! Address '5141 License No.�_Phone me <br /> TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Ll OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ---S.Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1"1 Public [ O+he �•.� F1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Appro.xx.._Depth I Eastern Surface Seat Installed by - <br /> Repair Work Done (], Type of Pu-mp�� State Work Done <br /> Well Destruction C7 V ell:Diameter Sealin-g-Material (top 501 \ <br /> Depth f"`i ,�•Filler�Material (Below,50'I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is <br /> .,.aqaP'IaibIq6vithjn 200 feet.) <br /> Installation will serve: Residence_ Commercial Other <br /> Number of i'living units: Number of bedropms <br /> Character of soil to a depth of 3 feet: 1 Wai tabEe depth <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments f� <br /> PKG. TREATMENT PLT. ❑ 'A{ �11W*4t Method of Disposal._ s <br /> Distance to nearest: Well Foundation " Property Line _"" <br /> LEACHING171No. & Length of lines "+ <br /> 1 g Tot I length/size <br /> I Distance to nearest" r f r f <br /> Foun tion Property Line _ j ✓ <br /> ti• � k <br /> SEEPAGE PITS ( I Depth i?e — Number I { <br /> 4 <br /> SUMS m. Cl Distance to n�arest: Wel[ �,_._.. oun <br /> Fdation Property Line <br /> DISPOSAL PONDS ❑ �" `•,� �� ' <br /> I herebycertify_that-t"hd pa pp ` a <br /> Y Ve-pre r this a iication r� that the•work'wil ba done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and-fegulations of the San Joaqu Local Health District. _ <br /> Home owner or licensed agent's signature cae7rti ies the following,!a certt(fy that!in t�he rformance-o ththeiwgrk for which this permit is issued, 1 shall not <br /> employ any perspn_insuch_manner as to become bject to workman's compensatto ws�f Cali rrt�'a" tracxor s hiring or sub-contracting signature <br /> certiiies,the following: "I certify that in the performa'&of the work for which title perq�it is i us ed,I shalTemplo arsons subject to work'man's compensa- <br /> tia�n,farws of California." � � / i <br /> applicant st tail for all required i pecuons. Complete draCring on everse`sid � r <br /> Signed �`� Title: .-1.' Ll <br /> " Date: <br /> DEPARTMENT`USt-ON.LY,, <br /> Application Accepted by '(Date `� z-$' .. <br /> '°�'� Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional,Coinm s: <br /> ❑ S* 66-6781 ❑ Lodi 3139=3621 ❑ Manteca 823.7104 ❑-Tiacy' 635-6385 <br /> Applicant - Return all copies to: Environmehtal Health Permit7Servicas iw E Hazelton Ave., P. Box 2009, Stk."CA 95201 <br /> FEE INFO AMOUNT DUE ; Ai410UNT REell7T.ED CK R .� <br /> H RECEIVED`8Y DATE kAWT•NO. <br /> +.EH13-21(REV.t/K51 yj��! - <br />