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APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br />1601 E. HAZEL T ON AVE., STOCKTON, CA <br />Telephone (209) 466-6781 <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 ��CC (�J � '�i3O" City �/� Lot Size 2 PM <br />Owner's Name <br />�'-�� Address V Phone <br />Contractor's Name <br />r ' License No. Phone <br />TYPE OF WELL/PUMP: <br />EW:WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br />PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br />DISTANCE TO NEAREST: SEPTIC TANK t SEWER LINES DISPOSAL FLD. PROP. LINE <br />/�DATE <br />FOUNDATION E AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br />-INTENDED-USE_TYPE-OF'WEiA7�- <br />-PROBLEM AREA-;'-CONSTRUCTION-SPECIFICATIONS <br />❑ Industrial <br />❑ Open Bottom ❑ Manteca, Dia, of Well Excavation Dia. of Well Casing <br />❑ Domestic/ Private <br />❑ Gravel Pack' ❑ Tracy "f Type of Casing Specifications <br />❑ Public <br />❑ Other ❑ DeltasDepth of Grout Seal Type of Grout <br />❑ Irrigation <br />—Approx. Depth ❑ Eastern Surface Seal Installed by <br />Repair Work Done ❑ <br />a� <br />Type of Pump ;I H'P. State Work Done <br />Well Destruction El <br />Well Diameter A Sealing Material atop 50,1.E �'•-{ - " <br />Depth I Filler Matef6l (Below 50T1 - <br />TYPE OF SEPTIC WORK: <br />NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br />available within•20b feet.) <br />Installation will serve: <br />Residence _ Other <br />Number of living units: <br />yCommercial <br />Number of_l4�e4r�ooms <br />Character of soil to a depth of,3 feet:--'•-���t r- lilies _ Water table depth /00 <br />SEPTIC TANK <br />❑ Type/Mfg ! Capacity No. Compartments <br />PKG.'TREATMENT PLT. <br />❑ Method of Disposal <br />Distance to nearest: We'll, FoGndationProperty Line <br />4 ,.. ,lee <br />ILerigth�of;lines <br />LEACHING LINE <br />'❑:= No.- & v '" " Total length/size <br />FILTER BED <br />❑ Distance to nearest: Well Foundation Property Line <br />SEEPAGE -PITS-.- <br />L� <br />Depih'�""""��-$ � Size � �.l Number <br />SUMPS <br />❑ Distance to nearest: Well _ V-9 Foundation 167 Property Line <br />DISPOSAL PONDS <br />❑ f <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." I <br />The applicant t call for all requir inspe 'ons. Complete drawing on reverse si e. q i� <br />Signed Title: tnJ Date: _ J 1 "- 4 <br />FOR DEPARTMENT USE ONLY '� ,� <br />Application Accepted by �! // //lt.� al-e-)Date��''��� Area / <br />Pit Grout Inspection by at Final Inspection by pf ate' <br />Additional Comments: <br />❑ Stk 466-6781 ❑ Lodi 369-3U1 1 ❑ 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 />+ EH 1324 (REV. 10!831 <br />EH 14-20 <br />INFO <br />AMOUNT DUE <br />AMOUNT REMITTED <br />CASH <br />RECEIVED BY PERMIT NO. <br />/�DATE <br />