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I <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES t'YEAR FROM DATE ISSUED <br /> ° T <br /> (Complete in Triplicate) <br /> 14 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 <br /> Job Address - rJ � J v� City /A <br /> Y G'. Lot Size PM <br /> Owner's NameC, . � � l 'C� e- Address Phone <br /> ContractorGf' Address 06 160 License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER LJ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - - _-� DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> 1 ' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ! <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications;,- tiP <br /> FI Public FI Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ,1 I Irrigation —_Approx: Depth l l Eastern Surface Seal Installed by _ <br /> Repair-Work Done— ❑ Type-of-Pump H.P. - State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth IFiller Material{Below 50') } <br /> ,TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 1-1 DESTRUCTION (,! (No septic system permitted if public sewer is I!­ <br /> t �* available within 200.feet.) <br /> Installation will serve: ResidenceI!' Commercial_ Other I? <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet i - {h Water table depth <br /> SEPTIC TANK �VType/Mfg 19.x-1_' �i ��fic.4` Capacity `� No. Compartments a <br /> PKC. TREATMENT PLT. ❑ 1 a ( _ Method of Disposal <br /> Distance to nearest: Well Foundation ..1 Property Line <br /> LEACHING LINE V No. & Len[gth of lines _ C( n� ` Tofal length/size 131 <br /> FILTER BED ❑ Distance,to nearest: Well. �J D Foundation /" T Property Line <br /> �. <br /> li <br /> SEEPAGE PITS 11 Depth I Size Num6er 13 <br /> SUMPS Ll 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, and <br />' rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signatbre certifies the following: "I certify that:in the performance of-the work for,which this permit is issued, I shall I= <br /> employ any person in such manner as tot 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 must call for all required inspections. Complete drawing on reverse side. <br /> r - ) <br /> Signed X Title: � �:Date: r. i` <br /> FOR DEPARTMENT USE ONLY f <br /> Application Accepted by Date / Area <br /> i <br /> Pit or Grout Inspection by Date Final Inspection by Date 7 <br /> r107 <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 a <br /> Applicant - Return all copies to: Environmental-Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNt DUE I AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. <br /> t.-EH1 -24(REV.'}/H 51 <br /> EH 14-26 <br />