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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT t <br /> 1601 E. HAZE 1 ON AVE., STOCKTON, CA 1 p� <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED A <br /> ' (Complete in Triplicate) <br /> application is f <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 app' _ <br /> made in compliance with San Joaquin County Ordinance No 9 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> ��� City Lot Size t� PM <br /> Job Addres � ` <br /> 040 I <br /> Owner's Nam <br /> Address � � p- Phone <br /> f Address License No. Phone <br /> +Contracto <br /> TYPE OF WELL/PUM NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION C] SYSTEM REPAIR ❑ OT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES', - <br /> DISP D. PROP. LINE <br /> FOUNDATION AGRICULTURE WEL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom anteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel P ❑ Tracy Type of Casing Specifications <br /> er I ❑ Delta Depth of Grout Seal Type of Grout —. (� <br /> f'l Public <br /> I Irrigation Approxi. Depth t I Eastern - Surface Seal Installed by - 1 <br /> Repair Work e ❑ Type of Pump <br /> H P State Work Done N <br /> Well D ruction ❑ Well Diame r Searing Materia! (top 50'1 <br /> Depthrt <br /> Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTION I 'afvailable within 200 feetit'ed if public sewer is <br /> Installation will serve: Residence "� Commercial_ :,Other <br /> Number of living units: Number of bedrooms <br /> + - Water table depth <br /> Character of soil to a-depth of 3 feet <br /> SEPTIC TANK Type/Mfg 'Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ f Method of Disposal <br /> Distance to nearest: Well Foundation Property.Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> r FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> t1 <br /> `+ SEEPAGE PITS 11 Depth; Size Number <br /> r SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that t have prepared this application and that the work will be done in accordance with San.Joaquin county ordinances, state laws, and <br /> I 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 become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: ""1 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 /> nt must call f all rvuired ins ctions. Complete drawing on revere dem - <br /> Signed X r <br /> Title: <br /> Date: <br /> f� FOR DEPARTMENT USEONLY <br /> �U(4 Date — Area- <br /> Application Accepted by 7 <br /> Pit or Grout Inspection b Data Final Inspection by Date <br /> Additional Comments: �2�0 <br /> ���❑ Stk 466-6781 ' ❑ Lodi 369- B23-7104 Uracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E..Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f <br /> FEE CK RECEIVED BY DATE PERMIVNO,/ <br /> AMOUNT DUE AMOUNT REMITTED <br /> INFO <br /> +.Eti 1324 tREV.i/H 5) C.) F�1 ��^ � <br /> EH 14-26 <br />