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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> F 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 /> Job Address :63 <br /> r rG <br /> City L Lot Size PM <br /> Owner's Name <br /> Zl � Address <br /> Phone <br /> 1 <br /> Contractor—1 tl./�zoz Address -0- 1 F <br /> License No.,���, phone - <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> ------PUMP-INSTAL-L•ATAON-E)-- SYSTEM REPAIR.❑ OTHER--pw-,,... i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL r OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well.Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy: Type of Casing <br /> f'1 Public i' ❑.Other Specifications <br /> - M Delia ` Depth of Grout Seal Type of Grout <br /> I R irrigation # ­.Approx. Depth IJ Eastern j <br /> . Surface Seal Installed by <br /> Repair Work pone ❑ Type of Pump { H p - <br /> State Work Done_ <br /> Well Destruction ❑ Well Diameter - Sealing Material Itop 50') <br /> Depth --i Filler Material (Below 50'I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION M REPAIR/ADDITION i I DESTRUCTION i I (No septic system permitted if public sewer is <br /> �� <br /> Installation will serve: Residence�omrriercial_ Other available within 200 feet.) <br /> Number of living units: _)Nurrlber of bedrooms <br /> Character of soil to a depth%'o 3 feet: + - <br /> SEPTIC TANK Water table depth <br /> i ❑.. Type/Mfg t {? L . _ i <br /> Capact �_ r <br /> r Y L No. Compartments <br /> PKG. TREATMENT PLT. ❑ r - <br /> t Method of Disposal <br /> k Distance ta`nearest: Well <br /> I ndation Ar7e Property Line ` <br /> LEACHING LINEr` ''�ybs �- <br /> ,7rQ No. & Le-'ngth of li" <br /> nes Total length/size <br /> FILTER BED - <br /> O Distance to nearest: Well-�undation �' "E;" <br /> - <br /> Property Line�� <br /> t <br /> SEEPAGE PITS ` I I Depth 'F Size <br /> Number <br /> SUMPS D Distance to'nearest: Wellt <br /> Foundation Property Line <br /> DISPOSAL PONDS, ❑ + <br /> „ t <br /> I hereby certify that I'fiave prepared this application and that' 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 /> Homo 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 al'required inspections."Complete drawing on reverse side. ; <br /> Signed X Title: l� <br /> Date: ' <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by / # <br /> _ Date jJ nn <br /> l - + Araa <br /> Pit or Grout Inspection by pate Final Inspection by <br /> Date <br /> Additional Comments: <br /> i t <br /> ❑ Stk 466-6781F CI 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 2bW,:Stk., CA 95201, <br /> FEE <br /> Y INFO' AMOUNT'DUE" " AMOUNT-REMITTED' <br /> CASH RECEIVEt) BY DATE---.=�E—R <br /> +.EH 13.24(REV.tins) <br /> EH„-2s �7A <br />