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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone {209) 466-6781 <br /> PERMIT EXPIRES 7 YEAR FROM.DATE"ISSUED <br /> �,. ,t F {Complete.in Triplicate) , > XlS'7'lic% !.✓ � <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work here"in'describThis 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 I�n? <br /> � � T A F City. C� --Lot Size LSO• PM1. <br /> Owner's Name \ Address &iAr ` <br /> e,L <br /> �^ _ Phone <br /> Contractor's Name r License No. 3 S+� PR Phone + <br /> TYPE OF WELL/ U NEW WE ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑. '' ' * , SYSTEM REPAIR )t1 OTHER 0' <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 /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing <br /> Domestic/Private ❑i0ravel Pack', © Trac Type of Casin <br /> � Y YI? g— 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 T-11-4— H.P. �l d. _ State Work Done 06Z.0. I <br /> Well Destruction ❑ Well Diameter ��_�r Sealing Material Itop 501 ' <br /> Depth Filler Material (Below 501 w f 11 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Wo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— sCommercial^• Other <br /> Number of living units: Number of bedrooms 4 <br /> i <br /> Character of soil,to a depth of 3 feet: Water table depth <br />' SEPTIC TANK 0„*T-ype/Mfg: Capacity_ No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal v <br /> Distance to nearest: Well "Foundation Property Line_ <br /> s <br /> • LEACHING LINE <br /> C1 No. & Length of Lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property'Line <br /> SEEPAGE PITS ❑ Depth.` Size Number -fr <br /> e. <br /> SUMPS � El Distance to�'nearest: Well Foundation Property�Line " <br /> DISPOSAL PONDS p <br /> r 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 licensedlagent's.sign'ature certifies the following: "I certify that in the performance of.thb work for which this permit'h issued, I shall not <br /> employ aAy person in such manner as to become subject to workman's.compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the following:awl certify that in the performance of the work for which this permit is•isgued,I shall employ persons subject to workman's compensa- <br /> tion laws of California:" <br /> The applicant st call for all required inspections. Complete drawing on reverse side. <br /> a <br /> Signed <br /> Title: Date:Date: <br /> FOR PARTMENT USE ONLY i <br /> Application Accepted byDate Area <br /> t - <br /> Pit or Grout Inspection byDate Final Inspection by ' _ Date t ' <br /> �A itional Comments: <br /> tk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑.Tracy 836-6385 <br /> pp ant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE <br /> CK <br /> s <br /> i <br /> INFO ° AMOUNT DUE AMOUNT REMITTED CASH 'RECEIVED BY DATE PERMIT"NO. <br /> t <br /> tr i <br /> EH 13.24{REV.1Ul931 <br /> EH 1416 �+ _ 1 1, � { •�` <br />