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r APPLICATION FOR PERMIT . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> r <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 /> r <br /> Job Address ,S%% '• ��,G/!'v �11� Cid, 1AiMiNq%•'.v Lot Size et&A!/ PM <br /> Owners Name Address '�' i y PJ%% Phone <br /> r <br /> Conttactoes Name ` N xl!I'L Ir %'-'i1' License No. 1 .- •'%% _ Phone <br /> TYPE OF WELL/PUMP: NEN/WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> r 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 O Gravel Pack ❑ Tracy Type of Casing - Specifications _ <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> r ❑ Irrigation --Approx. Depth ❑ 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 50') Cf% <br /> r Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted K public sewer is .t <br /> available within 200 feet.) <br /> Installation will serve: Residence y Commercial_ Other <br /> Number of living units: ✓:- Number of bedrooms <br /> Character of soil Io a depth of 3 feet: r Water table depth (1d, <br /> SEPTIC TANK Type/Mfg Capacity_1"01-, 6/V No. Compartments % t <br /> r PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well <br /> Foundation `-' r �' Property Line "• \ <br /> r LEACHING LINE ® No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation %o., Property Line <br /> SEEPAGE PITS ID Depth ! Size Number N <br /> h. SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 must call for all required inspections. Complete drawing on reverse side. <br /> Signed X /1'/:="la✓ Title: Date: i'n 1 <br /> w <br /> FOR DEPARTMENT USE ONLY �z f C t <br /> Application Accepted by 4 � -Date � �S `r Area O 1 <br /> Pit or Grout Inspection by kate,s- Date / Final Inspection by Date G � e� <br /> Additional Comments: <br /> ❑ Stk 466-Ml ❑ Lodi 369-3621 ❑ 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 /> r <br /> INTO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT�NO. <br /> L. EEu 10.16IBEv .torml �. - ---- - �`�tt/�'kt �i-113 `i <br />