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C , <br /> �. APPLICATION FOR PERMIT <br /> l SAN JOAQUIN,LOCALjHEALTH DISTRICT cz <br /> 1601 E. HAZEL T ON AVE.,•.STOCKTON, CA 1c <br /> ' Telephone{209) 466-6781 11�a <br /> PERMIT EXPIRES 7 YEAR FROM .DATE ISSUED <br /> T,.(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 <br /> Local Health District. the Rules and Regulations of theSanJoaquin <br /> Job Address <br /> City Lot Size p{U1, <br /> s _.. <br /> Owner's Name Address 7 Pho1,:PContractor Address License No. _ <br /> TYPE OF WELL/PUM 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 AGRICULTURE WELL <br /> OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia_ of Well Excavation Dia. of Well Casing f <br /> ❑ Domestic/Private ❑ Gravel Pack ClTracy Type;of°•Casing-°1 -N\! i Specifications <br /> r ❑ Public ❑ Other Delta ='A- •�+ <br /> i ❑, ' Depth of-Grout Seal Type of Grout <br /> ❑ Irrigation <br /> ---Approx. Depth f. Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump: H.P. _ .-State Work Done <br /> Well Destruction ❑ Well Dia,1f a er <br /> Sealing Material (top 50') _ <br /> i Depth Filler.Mate iral{geld 50'1, <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR•7-ADDIT.ION.❑—D.ESTR.UCTI_O_N AJNo septic system.Permitted if public sewer is <br /> i° available within 200 feet.) <br /> Installation will serve: Residence') Commercial I Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: 10. hw -. .1 Water table depth <br /> SEPTIC TANK �( r. . <br /> r X Type/Mfg ,.`�.CapacNo. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well °" `' <br /> Foundation Property LineNIA <br /> ' <br /> LEACHING LINE ❑ No. & Length of lines � IN Tota) length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ .Distance to nearest: Welf- 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 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 pMst call for all required inspections. Complete drawing on reverse side. <br /> A , <br /> Signed X ` - <br /> Title: Dater - 3,9 <br /> FOR DEPARTMENT USE ONLY <br /> Application Acceptedb 3` _ �� G(� <br /> Date Area '7 <br /> Pit or Grout Inspection y Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781_ ❑ Lodi 369-3621 ❑ Manteca 823-7104. ❑ Tracy 835-6385 i <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 w ) <br /> w <br /> FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE "7MiT' f� <br /> INFO <br /> + EH 13-24(REV.'l/A 5) <br /> EH 14-26 3J • �� ,. H.fr i <br />