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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> .Y 1601 E. HAZELTON AVE., STOCKTON, CA $^ <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> iApplication 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 /> f <br /> Job Address fCit - , !,�� _ <br /> 3 141f Y/O w 2" <br /> Y t fs c7 Lot Size PM <br /> Owner's Name Address Ph <br /> $� r <br /> r one <br /> 1 <br /> Colatractor = Address License No. Phone <br /> TYPE OF WELL/PUM NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' <br /> PUMP INSTALLATION ❑ ,, SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL_F_LD_. --PROP­t1N1` <br /> I FOUNDATION AGRICULTURE WELL '---BOTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEMS CDNSTRUCTION SPECIFICATIONS <br /> t <br /> Industrial —Open Bottom anteca Dia. of Well Excavation Dia. of Well Casing <br /> I ❑ Domestic/Private ❑ Grav c ❑ Tracy -t Type of'Casing Specifications <br /> I f 1 Public Other Cl Delta Depth of Grout Seal Type of Grout _. <br /> Irrigat, i_Approx. Depth 41 I Eastern Surface Seal Installed by <br /> pair Work Done ❑ Type of Pump H.P. State Work Done <br /> 2— <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler.Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION I ) DESTRUCTION (No septic system permitted if public sewer is <br /> " available within 200 feet.i r r� <br /> t Installation will serve: Residence Commercial_ Other f <br /> Number of living units: Number of bedrooms 4 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ 'Type/Mfg L""`CapacityNo. Compartments <br /> PKG. TREATMENT PLT- ❑ Method of Disposal <br /> Distance to nearest:T Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS L� • 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, 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: "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 must cal for all required inspections. Compl to ing on reverse side. <br /> Signed X ,ter <br /> tF^r Title: .e 7f r Date: S <br /> FOR DEPARTMENT USE ONLY 'p <br /> Application Accepted by Date 0 Area <br /> � ^ P y _ Date 5— <br /> Additional <br /> Pit or Grout Inspection by Date Final Inspection b <br /> Additional Comment D ` 1 L" 42 l.vZJ4 t,4 ej <br /> ❑ 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 ve , P.O. Box 2009, S 95201 I <br /> . =zc4 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> + EH 124{IiEV.riH5) <br /> EH 14 <br /> -26 �f� <br />