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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 1 YEAR FROM DATE ISSUED - <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. -. <br /> V City, Lot Size '�; ACf LI PM 05 9 <br /> Job Address <br /> .. -^ �1 Phone <br /> r�Address <br /> Owner's Name „ <br /> License No. 3 7 7 Q 1 r Phone . <br /> Contractor <br /> Address <br /> DESTRUCTION ❑ <br /> WELL REPLACEMENT ❑ <br /> TYPE OF WELL/PUMP: NEW WELL'© OTHER ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE; <br /> (i DISTANCE TO NEAREST: SEPTIC TANK �� OTHER WELL` PITS/SUMPS <br /> ,x FOUNDATION ' AGRICULTURE WELL - <br /> TYPE OF WELL PROBLEM AREA^ICONSTRUCTION SPECIFICATIONS <br /> ;1 INTENDED USE Dia. of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Industrial Specifications, <br /> Domesticl Private ❑ Gravel Pack ❑ Tracy Type of Casing ' r _<—.� s, t <br /> ❑ Delta Depth of Grout Seal ' Type of Grout <br /> El Public ❑ Other r 1 <br /> ---Approx. Dep Eastern Surface Seal Installed by <br /> ❑ Irrigation Stat or ne f <br /> H.P. <br /> Repair Work Done ❑ Type of Pump Sealing Material (top 50`7 <br /> Well Destruction ❑ Well Diamet , - <br /> Depth I Filler Material (Below 50'} <br /> TYPE OF SEPTIC' <br /> installation <br /> NEW INSTALLATION ❑ HE ❑ DESTRUCTION ❑ anvailablelwithin 200 feet.)stem if public sewer is <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: Nurriber of bedrooms „�� _,„ ✓, 'V1later table depth <br /> Character of soil to a depth of 3 feet: Capacity_�� No. Compartments <br /> SEPTIC TANK E3TYpe/Mfg-. q <br /> i Method of Disposal <br /> r PKG. TREATMENT PLT. ❑ ` Property Line <br /> Distance to nearest: Well Foundation <br /> Total length 1 size <br /> LEACHING LINE ❑ No. & Length of lines Foundation Property Line <br /> FILTER BED ED Distance to nearest: Well <br /> ;I <br /> ❑ Depth Size Number F <br /> SEEPAGE PITS Foundation Property Line <br /> 1. <br /> SUMPS <br /> r 11 Distance to nearest: well <br /> � <br /> DISPOSAL PONDS ❑ <br /> 1 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 /> k certify 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: "1es. <br /> ion <br /> of California.” <br /> workman <br /> employ any person in such manner hat n the come subject <br /> of the work for which th�iperm taws <br /> issued,I shall employ peo6onslsubj subject to wo-km ns sub-contracting mpensa- <br /> G, certifies the following:"I certify �, - .- . ,•� _ " <br /> tion laws of California." <br /> f The applicant st call f all required ' spections. omplete drawing on reverse side. 11 �( <br /> Title: <br /> Date: 12- <br /> ' Signed ' <br /> FOR DEPARTMENT USE ONLY J <br /> f �/J Date r r Area <br /> Application Accepted by <br /> Pit or Grout Inspection by <br /> I Date Final Inspection by peB <br /> Additional Comments: 835405 <br /> ❑ Stk 466-6781 ❑ Lodi i 369-3621 ❑ Manteca;$23 7104 F) Tracy <br /> Applicant- Return all copies to:j Environmental Health Permit/Seryices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i� {t EPER7MIT'NO. <br /> FEE GASH RECENEp 6Y DAT@ <br /> I <br /> INFO AMOUNT DUE AMOUNT REMITTED <br /> +•EH 13-241REV.1/651 <br /> EH 14-26 <br />