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APPLICATION FOR PERMIT=-`';:; <br /> SAN JOAQUIN LOCAL HEALTH'DISTRICT <br /> 1601 E. HAZEL—1 ON AVE., STOCKTON, CA <br /> Telephone (2pg) 466-6781 _ r, <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED+. ., <br /> Q,:�Ibt � `. : '�. (Complete,in Triplicate) <br /> and/or install the work herein described.This application is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules end Regulations of the San Joaquin <br /> Local Health District. <br /> ri t t. PM <br /> City of Siza. <br /> Job Address C b <br /> Phontons <br /> Address Owner's NamLicense No. � PhonContractor's Nam DESTRUCTION ❑ <br /> NEW WELL ❑ WELL REPLACEMENT ❑TYPE OF WELL/PUMP: SYSTEM REPAIR QOTHER ❑PUMP INSTALLATION ❑ SEWER LINES DISPOSAL FLD. PROPDISTANCE TO NEAREST: SEPTIC TANK gGRICULTURE WELL OTHER WELL PITS/FOUNDATIONINTENDED USE TYPE OF WELL PROBL- EMAREA CONSTRUCTION SPECIFICATIONSDia. of❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation SpecificT of CasinQ DomesticlPrivate ❑ Gravek Pack ❑ Tracy yAe g. e of <br /> " ❑ Delta'°""� ''Depth-of Grout Seal - "-gyp <br /> 7-1 Public ❑ Other I � { '' 0 <br /> El Irrigation �Approx. Depth ❑ Eastern Surface`Seal In-stalled-by "` G <br /> H:P... .-� State Work Done - <br /> Repair Work Done ❑ Type of Pump x - U <br /> 1�-^'� Sealing Material (top 56'1 <br /> Well Destruction El Well Diameters pth <br /> DrFiller Material (Below 56'1 <br /> Y e _ . setic permitted(No <br /> TYPE OF!" <br /> F EPTIC WORK: NEW 1NSTALLATIOFI REPAIAIADDITION Q DESTRUCTION El available within e200 feet.) if public sewer is � <br /> t Installation will serve: Residencez'Commercial— Other,— <br /> Number <br /> ther—Number of living units: Number of: edroomsd .¢f <br /> Water table depth i <br /> I Character of soil to a depth'of 3 feet: + Capacity9J2 — No. Compartments ' <br /> SEPTIC TANK Type/Mfg ���,,����A r Method of Disposal r- <br /> PKG. TREATMENT PLT. ❑ � T _, _ y }� Foundation Property Linet •� <br /> Distance to nearest: e i <br /> " No. & Length of lines t Total length-ize <br /> LEACFf/NG LINE g �,� . '"�"' . P-rope -Line-�—� <br /> FILTER BED ❑ Distance to nearest: Well�t -Foundation_� = 3 <br /> ff Sizei:- <br /> Number <br /> —maf <br /> SEEPAGE PITS ❑ Depth c � Property Une_�- <br /> SUMPS Distance to nearest:' Well "Foundation��— <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared this application'and that the work will be done in accordance with San Joaquin county ordinances, state laws, an <br /> rules and regulations_of-the San Joaquin Local H&Ith 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 sig <br /> shanature <br /> ll not <br /> employ any person in such manner as to become subject to workman's compensation laws f iC--ifarnia."Contracerson hiring suti ect t bwoorkmant'sgcompensa- <br /> certifies the following:"I certify that in the performance of the work for which this p rim,itis issued,I shall-employ pe 1__, <br /> tion laws of California." /} <br /> r The applica must call f all squired inspections. Complete drawing on reverse�idp // [ <br /> i Title: V Date: J <br /> .signed - <br /> . FOR DEPARTMENT USE ONLY � <br /> � - - --Area ` <br /> Date' <br /> �.- r <br /> Application Accepted by- <br /> at <br /> Pit or Grout Inspection by <br /> Date Final Inspection by <br /> 4 Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 D Manteca 623 7104 . Tracy 63''x6385 <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CK RECEIVED BY DATE PERMIT'NO. <br /> ffz-5 <br /> NT DUE AMOUNT REMITTED CASH <br /> ° <br /> _ rti77 <br /> +EH 1&24(REV.14!831 O <br /> EH 14.28 , <br />