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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 1 YEAR FROM DATE ISSUED <br /> 4 - r (Complete in Triplicate) <br /> I application is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work and-Regulations This app 1 <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for we <br /> and the Rules andSRgulations of the San Joaquin <br /> Local Health District. ,,;y � �` <br /> 1 f �� .\L7,4 t s <br /> f City �'` Lot Size PM <br /> Job Address �,9E <br /> , <br /> (� ����1 Phone <br /> Address <br /> Owner's Name L4,4 <br /> License <br /> r <br /> AC + License No. ® v Phone r <br /> Contractor's Name DESTRUCTION 11TYPE OF WELL/PUMP: NEW WELL F1 WELL REPLACEMENT L-1 ^ <br /> n..�- STEM REPAIR 11 -OTHER- IJPUMP INSTALLATION 1 SY, <br /> r ri S ' — �,p p{SPOSAL FLD. PROP. LINE <br /> EWER LlNE5'_. <br /> DISTANCE TO NEAREST: SEPTIC TANK__�L�_-_.� .. PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL i PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> —�— Dia. of Well Casing d <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation specifications <br /> Casing <br /> pomestic/Private 11 Gravel Pack —D.-Tracy Qepth of Grout Seal Type of Grout <br /> Li Public El Other " "'-r,El Delta <br /> ❑ irrigation l Other ox. Depth Eastern Surface Seal Installed by L <br /> Type of PumpH.P t P r State Work Done <br /> Repair Work Done ❑ t' t— <br /> Well <br /> Sealing Material Itop 50') <br /> Destruction ❑ Well Diameter <br /> Depth Filler Material (Below 501 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ �REPAIR/ADDITION ❑ DESTRUCTION ❑ aNailablelwithSne200 feet.) <br /> Ftted if public sewer is <br /> Installation will serve: Residence— Commercial Other <br /> Number of living units: r,;Number of bedrooms .�'� Water table depth <br /> Character of soil to a.depth of 3 feet: No. Compartments <br /> l SEPTIC TANK Q Type/Mfg ~Capacity <br /> '� a' Method of Disposal <br /> PKG. TREATMENT PLT. C] �� Foundation Property Line <br /> Distance to nearest: Well <br /> r- <br /> Total length/size <br /> LEACHING LINE ❑ Na. & Length of lines Property Line <br /> FILTER BED ❑ 1Oistance to nearest: Well Foundation <br /> ? s <br /> SEEPAGE PITS ❑ Depth <br /> ` Size Number Y <br /> SUMPS ❑ 'Distance to nearest: Well <br /> Foundation Property tine <br /> DISPOSAL PONDS ❑ <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 /> k that in the performance of the work for which this permit is issued, I shall not <br /> Home owner-or licensed agent's signature certifies the following: '9 certify <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certies 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 /> fi <br /> tion laws of California." i ' <br /> The applican 4st c it for all requi in pections. Complete drawing on rave se side. <br /> Title: 'I Date: <br /> Signed <br /> FOR DEPAR MENT USE ONLY y� <br /> Date Area V / <br /> Application Accepted by �(} <br /> I Final Inspection by Date <br /> Pit or Grout Inspection by i Date <br /> Additional Comments: <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 /> CK RECEIVED 8Y DATE PERMIT`NO. <br /> I FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO ` ^y � <br /> '+ EH 13-241REV,10193]- rIC7 <br /> EH 1426 <br />