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AeZ <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 'I'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 and Regulations of the San Joaquin <br /> Local Health District. j <br /> Job Address `S'�_--. / City Lot Size PM <br /> Owner's Name 1 rL✓YiXt.Ct~ y Address Phone <br /> Phone <br /> Contractor .,& e{ W-:_' Address o�536 61^ (AWU`d�" License NaOmm -Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL F_LD. PROP. LINE <br /> FOUNDATION. AGRICULTURE WELL 0 PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CO TION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Mantec Dia. of Well Excavation pia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack racy Type Of Casing Specifications <br /> fI Public ❑ Other CI Delta Depth of Grout Seal Type of Grout <br /> 1 1 Irrigation �. pprox. Depth l I Eastern Surface Seal Installed by _ ra <br /> Repair Work Don Type of Pump H.P. T ,_- _State Work Done <br /> Well Des ion ❑ Well Diameter Sealing Material {top 50'1 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I:). REPAIR/ADDITION t 1 DESTRUCTIONLACINo septic system permitted it public sewer is <br /> , )% vailable within 200 feet.) <br /> Installation will serve: Residence_ Commercial ^ Other '- <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC-TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT'PLT. ❑ e Method of Disposal <br /> Distance to nearest: Well Foundation 'Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: ' Well Foundation w Property Line <br /> e <br /> SEEPAGE PITS 1 ) Depth Size Number <br /> SUMPS ❑ 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 signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 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 ust call for all required inspections. Complete drawing on rev a side. <br /> Signed Title Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 'r Area LC> <br /> Pit or Grout Inspection by Date t Final Inspection by Date 2L I <br /> Additional Comments: <br /> ❑ Stk '466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 1335-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. F <br /> INFO P CASH <br /> ♦ EH 13-24 IAEV.i/r 5Y � �!_�( ��' 1� 0/ <br /> EH 14-29 llr••!•(7 /J <br /> i <br />