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-�;W <br /> APPLICATION FOR PERMIT <br /> I' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA S <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES T YEAR FROM DATE ISSUED <br />� r <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 /> Job Address City Lot Size PM <br /> Owner's Name. Address ��� C Phone <br /> Contractor Address :E• License No.�® Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR © OTHER ❑ - <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE — <br /> FOUNDATION AGRICUETURE WELL" "° "" OTF�ER'WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIO ATIONS <br /> Q Industrial ❑ Open Bottom ❑ Manteca ell Excavation Dia. of Well Casing <br /> .Q Domestic/Private ❑ Gravel Pack ❑ Tr 1. ' <br /> Type of Casing Specifications. .. . <br /> FI Public Ll Other Delta 4 Depth of Grout Seal Type of Grout <br /> I I Irrigation ox. Depth I 1 Eastern Surface Seal Installed by _ <br /> Repair Work Done Type of Pump H.P. �� State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material ftop 50'1 <br /> Depth Filler Material I6elow'50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION i l .DESTRUCTION Mo septic system permitted it public sewer is <br /> ,} . �, , available within 200 feet.I <br /> Installation will serve: Residence_ Commercial_ Other , <br /> Number of living units: Number of bedrooms <br /> Character of sail to a depth of­3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg Capacity" No. Compartments l <br /> PKG. TREATMENT PLT. ❑ R Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHINd`LINE L1No. & Length of lines I Total length/size <br /> FILTER BED ❑, Distance to nearest: WellFoundation Property Line <br /> SEEPAGE PITS i I Depth Size Number i <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line i <br /> DISPOSAL PONDS ❑ I _ <br /> 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. I <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 st call for all re uired inspections. Complete drawing on reverse side. ? if <br /> Signed X - - T..Title: /�A6 �'0 "T <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> 4 �.` i <br /> Application Accepted o� _ P.. . , .`+ - ` � Date 5^ � � Area <br /> Pit or Grout Inspection by Date Final Inspection b Date��2 <br /> 71 <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 Ymanteca 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 95201CK 0 <br /> FEE <br /> ) <br /> INFO AMOUNT DUI: AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. ' <br /> +.EH 1324 fREV. �JC1 n, <br /> EH 14-2e r1,.] ,;O <br />