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... 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 /> 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 Regulations of the San Joaquin <br /> Local Health District. n /-1 <br /> 1160 1 � Awl 1 '2 c) City M AA t�tit Lot Size �� PM <br /> Job Address 4 _ Phone 9 31 1 <br /> Owner's Name <br /> Sa7�}-� G I V L )�Address �� C 8.2 <br /> —T—"" CAle Address �$� License No. g39�1 Phone 9. <br /> Contractor <br /> TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION <br /> AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> Depth of Grout Seal Type of Grout <br /> M Public n Other 11 Delta _ <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by <br /> H P State Work Done _ <br /> Repair Work Done U Type of Pump � <br /> Well Destruction ❑ Well DiaTeter Sealing Material (top 501 <br /> Depth Filler Material (Belo 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITION DESTRUCTION (Noavaseptic systethin m rmit;ed if public sewer is C <br /> Installation will serve: Residence-ALI, Commercial <br /> Other <br /> Number of living units: I Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet. ( _12.0 No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg T 5 Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well amt Foundation Property Line <br /> u <br /> Total length/size �b <br /> LEACHING LINE No. & Length of lines <br /> 1 <br /> FILTER BED ❑ Distance to nearest: Well <br /> Foundation Property Line <br /> SEEPAGE PITS I I Depth Size <br /> Number 1 <br /> SUMPS Ll Distance to nearest: Well <br /> Foundation Property Line <br /> DISPOSAL PONDS Ci <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, <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 signature <br /> shall not <br /> employ any person in such manner as to become subject to workman's compensation laws ss California." ploy Contractor's <br /> lring or subject to workman's sub-contracting <br /> the following:"I certify that in the ormance of the work for which this permit is issued, I shall employ p 1 C <br /> tion laws of California." <br /> e. <br /> The applican 11 for all re ire <br /> ins ctions. Complete drawing on reverse side- _ pp <br /> Title: l�JDate: 0� <br /> Signed X <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> \-A Date � ` Area <br /> de I <br /> Pit or Grout Inspection by Date <br /> Final Inspection by Data <br /> Additional Comments: <br /> ❑ Stk 466-6781 O 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 /> CK RECEIVED BY DATE PERMIT•NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED S <br /> INFO ,r7 G <br /> EH 13-241REV.1/M5) -5 <br /> FH 1428 <br />