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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �— 1601 E. HAZE T ON 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 and Regulations of the San Joaquin <br /> Local Health District. <br /> � nn n <br /> Job Address QW) 1 e-A e 2 �1\2 G City_St Lot Size n(. a 9 4 L PM <br /> l i l ICA l � Address OyP 01 �e0 ee bI ij 1�— Phone �LO� - W <br /> Owner's Name -Z <br /> (�P�✓ fr� SIJ e License No. 3 39Z_! Phone y[o J <br /> Contractor's Name ' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ `N <br /> 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 /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ElIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> _ ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done - <br /> Weil Destruction ❑ Well Diameter Sealing Material (top 501 a <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 5Q REPAIR/ADDITION ❑ DESTRUCTION ❑ (No sepetic sywith tem permifeet ted if public sewer is <br /> Installation will serve: Residence_ Commercial z Other <br /> Number of living units:0 Number of bedrooms_sZ <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> Capacity No. Compartments -�}� <br /> SEPTIC TANK ❑ Type/Mfg \/ <br /> Method of Disposal <br /> PKG. TREATMENT PLT.❑ <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No- &Length of lines <br /> Total length/size-- <br /> FILTER <br /> ength/size —FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS PO Depth Ps Size Number <br /> SUMPS ❑ Distance to nearest: Well poy�f! �6/ Property Line— Foundation V <br /> DISPOSAL PONDS ❑ 11n Qr pUL <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 r <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 m call f , required inspections. Complete drawing o reverse ide. <br /> Title: _Y_ —_ Date: <br /> Signed <br /> FOR DEPARTMENT USE ONLY T� f <br /> _� Date � Areay` <br /> Application Accepted by <br /> Final Inspection by ate <br /> Date <br /> Pit or Grout Inspection by <br /> Additional Comments: �--�- --7 racy <br /> ElSgc 466ZA11 ❑ Lodi 369-3621 ElManteca <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE RCASH RECEIVED BY DATE PERMIT NO. <br /> AMOUNT DUE AMOUNT REMITTED <br /> _ INFO <br /> 3�Z �11-31ts <br /> + EH 1324(REV.10/83) S, p,� ILA _._ <br />