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l APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f 1601 E. HAZELTON AVE., STOCKTON, CAS <br /> I Telephone (209) 466-6781 acribed <br /> ir �PERMIT EXPIRESTYEAR FROM DATE ISSUED .(Complete in Triplicate)Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein ppli s <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 /> 0a Z <br /> Job Address City Lot Size PM <br /> Owner's Name Address <br /> Phone4/�; ,< <br /> Contractor A9V,4-1StJ Address L.s- ,License NC,3 Phone/ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LJ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL ELL PITS/SUM <br /> INTENDED USE TYPE OF WELL PRO BLEM.ARE - Tf3lJC1 IOfV SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ ca Dia. of Well Excavation Dia. of Well Casing <br /> D Domestic/Private ❑ Gravel Pac ❑ Tracy i Type of Casing Specifications f <br /> ❑ Public LJ ❑ Delta Depth of Grout Sea! V <br /> J P Type of Grout <br /> f I Irrigation --Approx. Depth l I Eastern r'+Surface Seal Installed by <br /> Repair Work e Ll Type of Pump H.P. -.. <br /> . State Work Done <br /> W truction ❑ Well Diameter. Sealing Material,(top 501 <br /> Depth I: Filler Material (Below 50'1 f <br /> TYPE OF SEPTIC,WORK: NEW INSTALLATION Cl REPAIR/ADDITION I I DESTRUCTION INo septic`system permitted if public sewer is Z <br /> J �--.- ,-..r�,�._..,_...,,__ ——, vailable within 200 feet.) <br /> Installation will serve: Residence Commercial— Other ( r I <br /> Number of living units:\ Number of bedrooms <br /> Character'of soil to a depth of 3 feet:' Water table depth <br /> SEPTIC TANK , ' ❑ `Type/Mfg} Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ f Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of tines f Total length/size <br /> FILTER BED ❑ Distance to nearest: Well ' Foundation Property Line <br /> f <br /> SEEPAGE PITS i I Depth Size k- - Number <br /> SUMPS ❑ Distance to neatest: well Foundation y Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this iapplication 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 taws of California," <br /> The applican ,ust call for all required inspections. Complete drawing on r rse side. <br /> Signe Title: <br /> Date: <br /> F EPARTfMENT USE ONLY <br /> Application Accepted by .r DateG" Area 3 <br /> Pit or Grout Inspection b `� <br /> Date Final.Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ;I <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO RECEIVED BY DATE PERMIT NO. <br /> EH N-28 <br /> + EH 13-24(REV.I/K5) G <br />