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f r r <br /> r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ?� <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (2W-� � j <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � l <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 /> c r <br /> Job Address 1�11R rl1a­117' U� _ Cit l T tot Size PM <br /> Owner's Name <br /> Address301-17L Phone - .? h <br /> a <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 01-7 <br /> DISTANCE TO NE SEPTIC TANK SEWER LINES DISPOSAL FLD. N <br /> FO TION GRICULTURE WELL LL PITS/SUMPS <br /> INTENDED USE TYPE OF WEL PROBL NSTRUCTION SPECIFI S <br /> ❑ Industrial ❑ ca Dia. Well E Ca ion Dia. of Well Casing <br /> mesticlPrivate ❑ Gravel Pack ❑ Tracy T Cas Specifications <br /> f'l Public n Other + ❑ Delta De f Grout Seal Type of Grout <br /> I Irrigation --Approx. Depth 11 Eastern Surface Se tailed by <br /> Repair Work Done ❑ Type of Pump H.P. ate Work Do <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION i I DESTRUCT( o septic system permitted if public sewer is 9 <br /> available within 200 feet.) <br /> Installation will serve: Residence_' Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth �1 <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ i Method of Disposal <br /> Distance to nearest: Well Foundation Property Line i f <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS Cl Distance to nearest: Well ""FoundAtion Property Line <br /> DISPOSAL_ PONDS ❑ <br /> 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 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 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 must call four fall required inspections. Complete drawing on reverse side. <br /> Signed X )-n__ -4 Title- Date: X"' ,t— kr <br /> FOR DEPARTM T USE ONLY <br /> Application Acceptegn _� <br /> Dated Area <br /> Pit or Grout Inspecti / Date ` Final Inspection by Date <br /> h3k3 <br /> Additional Comments: t P/U /.1 ® �[ 24AOLat16&&= if <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 /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> +.EH 13-241REV.i/Ksl <br /> EH 14-28 <br />