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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 /> a <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 I <br /> Locale Health District. i <br /> 614 City Lot Size PM <br /> Job Address a+ 0 <br /> Address O Phone <br /> Owner's NameA;0 r' "` <br /> - �f - <br /> 3License No. S S5�X17 Phone 1/6-63ff 5 <br /> Contractor <br /> Address <br /> TYPE OF WELL/PUMP: NEW WELL E3 WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION C3J SYSTEM REPAIR ❑ OTHER ` <br /> DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES 1 — DISPOSAL FLD. OOf PROP. LINE b0 - <br /> 5J AGRICULTURE WELL OTHER WELL— <br /> INTENDED <br /> FOUNDATION �..�— <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well�Excavat � J— <br /> t� Specifications <br /> p Domestic lPrivate d Grave! Pack ❑ Tracy Type of Casing Type of GroutlL + � <br /> (7 Public 1-1 Other F1 Delta Depth of Grout Sea! <br /> I I Irrigation ._—.Approx. Depth t I Eastern Surface Seal Installed by. <br /> Repair Work Done ❑ Type of Pump <br /> H P State Work Done <br /> Well Destruction ❑ Well Diameter JL/� Sealing Material (top 50') <br /> Depth 42=eg .� Filter Material (Below 50') . <br /> TYPE OF SEPTIC WORK: NEW iNSTALLATION l 1 REPAIRlADDITION i I DESTRUCTION I I afvailableseptic <br /> wi within 200 feet fed if public sewer is <br /> Installation will serve: Residence_ Commercial—.. Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. El <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I i DepthSize Number <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line <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, an <br /> rules and regulations of the San Joaquin Local Health District. <br /> he following: "1 certify 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 t <br /> compensation taws of California." Contractor's hiring or sub contracting signature <br /> any person in such manner as to become subject to workman's <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall em�oy pe son to workman's compensa- <br /> tion laws of California." <br /> The applicant l$t it for all required iKapeations. C plate drawing on a <br /> Signed verse jside.�f�'" , Gf <br /> X Title: � y -- <br /> „ - - - �- <br /> FO A USE ONLY <br /> Date G � O Ara <br /> Application Accepted by _ p <br /> Pit or Grout Inspection by <br /> Date final Inspection b Date <br /> ; <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 CI 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 /> FEE CK RECEIVED BY DATE PERMITtID. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH v//+ <br /> . EH 13-24 IREV, <br /> EH 1t-26 <br />