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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCA_ L HEALTH DISTRICT <br /> 1601E. H <br /> AZELT'ON AVE., STOCKTON, CA � <br /> Telephone (209) 466-6781 <br />` HAL�kI <br /> PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> s� a f P"L <br /> (Complete in Triplicate) S�Rv10ES <br /> Application is hereby made to the San Joaquin Local Health District fora 1. <br /> C. made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welt/pump and the Rules and in desribedof <br /> permit to construct and/or install the work herein described. This application is <br /> Local Health District. <br /> the San Joaquin <br /> Job Address ; s` <br /> A A r City r7 Lot Size <br /> Owner's Name PM <br /> -Address.: . <br /> Contractor r Fr, ! Pho <br /> n <br /> e <br /> f'y Address � _ <br /> TYPE OF WELL/PUMP: License No. Z <br /> NEW WELL. _ WELL REPLACEMENT ❑ Phone <br /> PUMP INSTALLATION DESTRUCTION ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ 01 [jFOUNDATION <br /> SEWER LINES` DISPOSAL FLD, <br /> AGRICULTURE WELL <br /> INTENDED USE _ _ OTHER WELL��` <br /> ROP LINE <br /> TYPE OF WELL 'PR08LEM ARBA . 'CONSTRUCTION SPECIFICATI�iyiS PITS/SUMPS. <br /> ❑ industrial - s <br /> ❑ Open Bottom ❑ Manteca Dia. of WeU Excavati n - <br /> Llomestic/Private ❑ Grave! Pack pias y__ <br /> ❑ Public Type of Casing Weil Casing <br /> racy <br /> ❑ Other ❑ Delta S ifications l p' <br /> ❑ Irrigation Depth of Grout Seal <br /> ---Approx. Depth ❑ Eastern Surface Seal Installed by �jy� of Grout P_ <br /> Repair Work Done ❑ Type of Pump C`it <br /> Weil Destruction ❑ Well Diameter H.P. State Work Done t <br /> Sealing Material(top 50') <br /> Depth <br /> TYPE Filler Material(Below 501) <br /> OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No se tic <br /> Installation will serve: Residence p system permitted if Public sewer is <br /> Commercial t available within 200 feet• <br /> Numb } <br /> Number of living units: Other <br /> Number of bedrooms <br /> Character of soil to a depth of'3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Water table depth <br /> PKG. TREATMENT PLT. ❑ ' CapacitV� No. Compartments <br /> Distance to nearest: WellMethod of Disposal <br /> Foundation—�� Property Line t <br /> LEACHING LiNE ❑ 'N6.& Length of lines ' s <br /> FILTER BED ❑. Distance to nearest: Well Tatal length/size s <br /> Foundation^_ Property Line <br /> SEEPAGE PITS ❑ Depth Size <br /> SUMPS ❑.-:Distance to nearest: WellNumber r <br />- �.r–DISPOSAL--PONDS-- Foundation Property Line <br /> by <br /> ify that <br /> ve <br /> his <br /> rules and ndc regulations ulationsl ofathepS n Joaquin uin Localation and that Health District.he work,will be done in accordance with San Joaquin county ordinances, state <br /> g qlaws, and ' <br /> Home owner or licensed agents 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 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 call for p1l rsiI inspections. Complete drawing on rse side. <br /> elf <br /> Signed Title: <br /> - Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date r - <br /> Pit or Grout Inspection by Date} �� Final Inspection by � <br /> Additional Comments <br /> ❑.Stk 466 6781 ❑ Lodi 369-3621 ❑ Manteca ^- 104 <br /> 0 Tracy Applicant- Return all copies to: Environmental Health Permit/Services 1601E Hazelton Ave., P,O, ` t t ► - <br /> • - E�iIAgQ$�I�n��A�4�Al.TH <br /> FEEPERMIT/SERVICES <br /> INFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE <br /> PERMIT NO. <br />+EH1 -24fREV.tie51 <br />•�EH 1426 � • <br /> 4S # <br />