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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601E HAZE 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 Joaquin Local Health District for a permit to construct and/or install the work herein described. This <br /> made H 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. hts application is <br /> i <br /> Job Address / 7S t <br /> l City Lot Size PM <br /> + <br /> Owner's Name �', / n <br /> Address <br /> Phone "3u� <br /> I Contractor <br /> Address <br /> TYPE OF WELL/PUMP: License No. phone_ <br /> NEW WELL WELL REPLACEMENT D <br /> PUMP INSTALLATION DESTRUCTION ❑ <br /> DlSTANC NEf4R�ST: EPTIC TANK r' SYSTEM REPAIR ❑ OTHER,.El-. <br /> SEWER LINES n <br /> FOUNt7,�lOfsl �-� DISPOSAL F✓=D �PROP. LINE �O <br /> AGRICULTURE WEL r G`I`HrR WEL _ �! _ PITS/SUMPS , <br /> INTENDED USE TYPE OF WELL PROB Ehf <br /> ❑ Industria! --� �� CONS CTION SPECIFICATIONS <br /> ❑ Open Bottom 11 Manteca <br /> omesUc/Private of Well Excavation <br /> ❑ Gravel PackDia. of Well Casing <br /> Q Public 'r Ylta Type of asitLQ <br /> C1 Other Cl DeSpecifications <br /> ' Irrigation Depth of Grout S <br /> —�Ap fox. Depth I 1 Eastern Surface Seal Installed by Type of Grout r <br /> Repair Work Done .�..-ts`y"pe of Pump 1_ <br /> Well Destruct" ~�— H.P. State Wor a !G <br /> ❑ Well Diameter Sealing Material {top 5o'I <br /> Depth Filler Material IBelow 50') <br /> :TYPE OF SEPTIC WORK;- NEW INSTALLATION I 1 REPAIR/ADDITION I i DESTRUCTION ( I Wo septic system permitted if`public sewer i <br /> Installation will serve: Residence available <br /> Commercial 3 Other within 200 feet.) s <br /> Number of living units: __�_ Number of bedrooms ! <br /> Character of soil to a depth of 3 feet: t/fr / <br /> SEPTIC TANK 177) Type/Mfg Water table depth U <br /> PK& TREATMENT PLT. D Capacity No. Compartments 21 <br /> rr <br /> Distance to nearest: Well (}' Method of Disposal <br /> Foundation Property Line <br /> LEACHING LINE ❑ No. $ Length of lines <br /> FILTER BEDTcLtal length/size .R <br /> ❑ Distance to nearest: Well i <br /> lL Foundation ` property Line <br /> SEEPAGE PITS <br /> I ! Depth S Size <br /> SUMPS Ll Distance to nearest: Well aQ� Number <br /> F <br /> DISPOSAL PONDS oundation l�t� Property Line <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 /> employ any person in such manner as to become subject to er <br /> rules and regulations of the San Joaquin Local Health District. {r <br /> Home owner or licensed agent's signature certifies the following: "I certify that inithe performance of the work for which this permit is issued'! shall not 1 <br /> 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, !shall employ <br /> tion laws of Cali nia." p F <br /> P y persons subject to workman's compensa- <br /> tion <br /> i <br /> The applicant t ail for alr l-qui s <br /> pections. Complete drawing on reverse side. � <br /> Signed X fl . <br /> - Title: <br /> Date: _ <br /> 1_7 FOR DEPARTMENT USE ONLY <br /> Application Accepted by f <br /> Date Area <br /> Pi or Grout Inspection by <br /> Date–� inal Inspection by <br /> Additional Comments: 1 Date <br /> r w <br /> ❑ Stk 466-6781 Cl Lodi 369-3621 �' ] Manteca 823-7104 Y <br /> Applicant - Return all copies to: Environmental HAelth Permit/Services 1601 E�azelt n ty 3Ave., P.O. Boz 2089, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK ` <br /> CASH RECEIVED BY •DATE' <br /> r.EH 13-24(REV.t i n s) INFO PERMIT NO. <br /> EH 14-2g 0 0 t <br />