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APPLICATION FOR PERMIT d <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA L <br /> Telephone (209) 466-6781 �• <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> is <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. L <br /> 19 <br /> Job Address �� City Lot Size PM <br /> Owner's Name _ Address <br /> Gontracto ! JAddles3o `S3 � r_J - �License ag&y& Phone OJ, <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> _ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES AL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WE�PROBLCONSTRUCTIONSPECIFICATIONS <br /> ❑ Industrial ❑ Open BottoDia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gfavel ❑ Tracy Type of Casing Specifications' <br /> f7 Public er f 1 Delta Depth of Grout Seal Type of Grout _. <br /> I 1 Irrigation _.-Approx. Depth 1 ) Eastern Surface Seal Installed by <br /> Repair W one ❑ Type of Pump H.P. State Work Done <br /> estruction ❑ Weil Diameter Sealing Material (top 50') 1 <br /> Depth Filler Material {Below 501 _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l T REPAIRIADDITION {.1 DESTRUCTIO (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character-of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK.4 ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal I <br /> ,. Distance to nearest: Well Foundation Property.Line <br /> 1 <br /> LEACHING LINE ❑ No. 8 Length of tines t Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS I] Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 /> 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, 1 shall not <br /> employ any person in such manner a_s to become subject to workman's compensation laws of California." Contractors hiring or subcontracting 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 ust call for all requited inspections. Complete drawing on reverse side. Ja <br /> Signed Title: �%t. � Date: _2!2— <br /> if 1FOR DEPARTMENT USE ONLY Q <br /> Application Accepted by U­�u--) t DateSVS " Area r <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> A ditional Comments: <br /> l Stk 466-6781 ❑ 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. Bax 2009, Stk., CA 95201 <br /> 1Nf0 AMOUNT A AMOUNT REMrrr CK RECEIVED BY DATE PERMIT NO. <br /> +.EH 13-24 MEV.r/e 51 17-1s47 <br /> EH 74-28 <br />