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I. <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT c <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 4Gr%.6Wg <br /> ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> it (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/of 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 woupump and the Rules and Regulations of the San Joaquin <br /> Local Health District. ��� <br /> Y 5x 19 <br /> City Lot Size PM <br /> Job Address <br /> i Vr <br /> 1 Address Phone <br /> Owner's Name <br /> Address License No. Phone <br /> Contractor <br /> TYPE OF WELL/PUMP:. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑_,,,, <br /> PUMP INSTALLATION 171 SYSTEM REPAIR ❑ OTHER LJ <br /> SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. UNE <br /> DISTANCE TO NEAREST. S <br /> FOUNDATION AGRICULTURE WELL OTHER WELL. PITS/SUMPS <br /> INTENDED USE 'TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial [i Open Bottom L1 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ! Type of Casing Specifications <br /> ❑ Domestic/Private © Gravel Pack ❑ Tracy 9 _ t h <br /> {"1 Public <br /> .� D Other Vi Ll Delta Depth of Grout Seal Type of Grou4 <br /> I I hrigatiery �..Appro- Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done ElType of Pump H.P. State Work Done <br /> Well Destruction 0 Well Diameter Sealing Material (top 501 i <br /> Depth Filler Material (Below 501 wk <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 7 REPAIfllADDITION l 1 DESTRUCTION I availableINo 'withinB200 feet.)tted f public sewer is <br /> �-- Installation will serve: ' Residence Commercial'_ Other r j' _.. W <br /> Number of living units: Number of bedrooms w .-. .. <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK El Type/Mfg Capacity No. Compartments <br /> IXPKG. TREATMENT PLT. ❑ Method of Disposal <br /> . 1 <br /> Distance to nearest: Well Foundation Property Line <br /> f'^ 4 <br /> LEACHING LINE L1 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS f I Depth Size Number <br /> SUMPS L_l Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 1 <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 /> rtify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I ce <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 /> i The applicant must-call for allWired ins ctions. mplete drawing on reverse side. <br /> I <br /> SignedX_ Title: Date: <br /> I FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date area <br /> 1 Pit or Grout inspection by . Date Final inspection by ata f 7 <br /> Aff <br /> ti <br /> Additional Comments: 'L <br /> ❑ 5tk 466-6781 ❑ Lodi 369- 1 ❑ Mant 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUN11 <br /> T REMITTED CK RECEIVED BY DATE ?ERMIT NO. <br /> INFO (�+ CASH /�/{� <br /> + EH I 124IREV.11951 J G(/ ,� <br /> EH 14-2e <br />