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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f 1601 E. HAZEL T ON AVE., STOCKTON, CA � <br /> Telephone (209) 466-6781 <br /> 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED P410 Ze� .� <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 applicaiion-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 /> Job Address + F City- 0 L-L2 Lot Size <br /> PM <br /> - <br /> Owner's Name Address Phone/ <br /> f - <br /> Contractor Address �• �.( License N �q Phont —ISO <br /> TYPE OF-WELL/PUMP:. NEW WELL ❑ WELL REPLACEMENT ❑ D 1 <br /> ESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSA E <br /> FOUNDATION AGRICULTURE WELL THEIR WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM ARE NSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom E] ..-`—'ca Dia:of 1NelI Exca`vation'T' 1 <br /> F Dia. of Well Casing + <br /> ❑ Domestic/Private 0 Gravel Pack Tracy Type of Casing Specifications i <br /> M Public n Other' ❑ Delta Depth of Grout Seal <br /> I I Irrigation _ Type of Grout—_­ <br /> —.Approx. <br /> rout _ I <br /> 1 —.Approx. Depth I 1 Eastern Surface Seat Installed by <br /> Repair Work Do Type of Pump H.P. State Work Done'_ <br /> Well D ction ❑ Well Diameter Sealing.Material (top 501) g� <br /> Depth i Filler Material (Below 50'1 I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION !'l REPAIR/ADDITION.i.,l DESTRUCTIO .(No septic system permitted if public sewer is. <br /> E 'k" t .. availablefeet.) t <br /> Installation will serve: Residence within <br /> Comme iaf Other 1 - � 200 <br /> Number of living units: Number of bedrooms '� t <br /> Character of soil to a depth of 3 feet: <br /> Water table depth <br /> SEPTIC TANK Type%Mfg ,', w t»-�^----^—�-Ca acit ."a.." �., <br /> P Y s No. Compartment <br /> PKG. TREATMENT PLT. ❑. �- � I <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property.Line <br /> LEACHING LINE ❑ No. &Length of lines Total length/size <br /> FILTER BED ,.i! ❑ Distance to nearest: Well ;Foundation r' <br /> s r - Property Line <br /> SEEPAGE PITS�'�'~-I.I.,,,^Depth¢ 1 Size ' " t <br /> Number i <br /> SUMPS ❑ Distance to nearest: Well Foundation <br /> I <br /> DISPOSAL PONDS- Property Line-, ❑ � - -V— 1 <br /> r <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Jo aquin 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,1 shall empl <br /> tion laws of California." <br /> oy persons subject to workman's compensa- <br /> The applicant st call for all required in ct' ns. Complete drawing on reverse side. <br /> Signed X <br /> Title:. .C+ <br /> — _-Date: <br /> Y <br /> FOR DEPARTMENT USE ONLY r {'y� [x��y <br /> Application Accepted by ' Date <br /> Area <br /> Pit or Grout Inspection "" Date Final Inspection b lj i <br /> a � a Date I <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835- 5 <br /> Applicant - Return all copies to: Environmental Health Permit/Services,1601 E. Hazelton Ave.!,P.O. Box 2009, Stk., CA 95201 <br /> FEE CK I� <br /> INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY <br /> CMH RRECEIVE / DDAATE�/ PERMIT'NO.. <br /> {REV. <br /> +,EH 13-24 .�� � <br /> EH 14-28 <br /> , <br />