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APPLICATION .FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. 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 San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance <br /> Local Health District. <br /> ' /[ 1 City Lot Size QM <br /> Job Address <br /> �� ess ! 7�5� �'4. f" ,� Phone <br /> Owner's Name <br /> U Address License No. <br /> Phone9r <br /> Contractor - <br />` TYPE OF WELL/-P: NEW WELL Li SWELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> d „pU�AP INSTALLATION ❑ SYSTEM REPAIR ❑ O HER ❑ � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPO PROP. LINE - <br /> FOUNDATION`-- AGRICULTURE WELL HER WELL PITS/SUMPS <br /> T10N SPECIFICATIONS <br /> INTENDED U;E TYPE OF WELL" PRaBI FM AREA CO UC .Dia:of Well Casing + <br /> ❑ Industrial ,?,.,,.,�•r- D_Open Bottom"�,. ❑ Manteca Dia. of Well Excavation � e <br /> �^ f CasingSpec cations <br /> ED Domestic/Private ❑ Gravel Pack' ❑ TO <br /> ❑ Other Delta Depth of t Seal Type of Grout <br /> }• ro epth, 0.Eastern)k i Surface Seat In by .9 <br /> k t Irrlgalion�—app / <br /> t ump ° c, H:p- Sta ork Done 4 <br /> 'ie air WorkFDone OT <br /> Well Destruction, ❑i"�Wetl Diameter r Seal ni g Material:(top 51 •+ `►`1 <br /> l ll Z <br /> Depth -- Filler Material(Below 501 <br /> TYPE OF SEPTIC WORK:- NEW INSTALLATION REPAIR/ADDITION ❑ DES_TR /-availabpeIN lwi system <br /> co 200 feetltl� if publi sewer is <br /> � <br /> Installation will serve: Residence_ Commercial Other <br /> Number of living units: Number of bedrooms Lwaledepth <br /> Character of soil to a depth of 3 feet: <br /> Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Dispos I <br /> III TREATMENT PLT. (� M4 � �� /� Sd <br /> Distance to nearest: Well L:FoundatioriA_1[-! Property Line <br /> LEACHING LINE JKII & Length of line Notal length/size <br /> } o ` `� Property Line <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> I Number <br /> SEEPAGE PITS ❑ Depth Size <br /> SUMPS ❑ Distance to nearest: Well <br /> If Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> , <br /> I hereby certify that I have prepared-this application and that the work will be done in accordance with,San Joaqum 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�th ork fol which this permit is issued, I hall not <br /> employ any person in such manner as to become subject to workman's compensation laws of Califo`}rna:' Contracor'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." r € <br /> The applicant must call for 1 requird inspections. Complete drawing on reverse side. ., ��--��iiii r <br /> Si ned _ w Title: ro dd AlIx 0�' Date: J <br /> g ,;. "� <br /> FOR DEPARTMENT USE ONLY E <br /> DateArea s <br /> Application Accepted <br /> } Date Z121 Final Inspection b Datilf — 17 <br /> Pit or Grout Inspection y <br /> Additional Comments: <br /> I Stk 466-6781 L3Lodi 31 3621 ❑ Manteca 823-7104 ❑ Tracy 83543>35 � <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 <br /> i <br /> FEECK RECEIVED BY DATE <br /> PERMIT'NO. <br /> INFO 4OUNT DUE AMOUNT REMITTED CASH <br /> r <br /> + EH 13-24(REV.r/a 51 �. <br /> EH 14-26 g <br />