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APPLICATION FOR PERMIT <br /> i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE, STOCKTON, CA <br /> Telephone (209) 466-6781x„ <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 /> t Local Health District. 3 <br /> C <br /> Job Address /C,/ L -Xli� " <br /> i ity. (�tea iy.Lot Size PM <br /> Owner's Name Phone <br /> Contractorddress + <br /> �'•'Cicense No. �_-5� 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 FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBON SPECIFICATIONS <br /> LEM AREA CONSTRUCTI <br /> ` _�i I <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack �Q Tracy Type of Casing Specifications <br /> ❑ Public f ❑ Other" .❑`IDelta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. De th `Q':Eastern r. Surface Seal Installed by <br /> Repair Work Done-•❑ Type of Pump `H;p,: State Work Done <br /> Well Destruction ❑ Well Diameter " t` Sealing Material flop 501 <br /> Depth " ° Eller,Material (below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION'134 REPAIR/ADDITION X DESTRUCTION ❑ iNo septic system permitted if public sewer is <br />+ F '' a s available within 200 feet.) <br /> Installation will serve: Residence�xx Commercial— Other t { <br /> Number of living units: Number-.of bedrooms <br /> Character of soil to a depth of 3 feet: �'r°.` Water table depth. <br /> - SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> i PKG. TREATMENT PLT:❑ "t <br /> i s Method of Disposal. <br />' Distanceto nearest: 'f-°'WeP .'0 ? Foundation Property Line .� <br /> LEACHING LINE No. & Length of lines Total E'�JY� Total length/size <br /> FILTER BED ❑ Distance to nearest.—Well= � <br /> y FoundationProperty L"ine a '-' <br /> .R- f _ f <br /> SEEPAGE PITS :Oepth # f�;.,r` Srze -'. X� R.� Number <br /> SUMPS ' Distance t'o nearest: Well (j'tr <br /> urlda.i�n-rV- <br /> Property Lire <br /> w. DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this4applicaton 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�becomeSsu bject-toworkman:s.compensation-Iaws.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." I F <br /> The applicant must call for all r aired inspectio to drawing on reverse side <br /> t Signed Title: Date: <br /> iF RTMENT USE ONLY p� <br /> Application Accepted by - �. .Qw�,.1 .. _-.Date , Area <br /> Pit or Grout Inspection by 1 Date Final Inspection by Dy Z <br /> ate _LZ <br /> Additional Comments: <br /> s <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave. P-0. Bax 2009 Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED. R CK 4 <br /> CEIVED BY <br /> INFO SH �DATE PERMITNO. <br /> + EH 13-24 fREV,I/n 51 <br /> EH 1429 <br /> U v I <br />