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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCA .,, <br /> 1601 <br /> DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 r A;. . �• <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate] a' <br /> .. , <br /> for sewage or No. 1862 for welllpump and the Ryles and Regulations of the San Joaquin <br /> 'on is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein.described.Thos application is <br /> Applicati r <br /> made in compliance with San Joaquin Coy yty Ordinance N t a <br /> '`Local Health DistrictPM <br /> I Lot Size-------- <br /> 5- i 1 <br /> PhoiJob Address `�1r e <br /> Address T <br /> Owner's Name A1� Phone T 1 <br /> Address � fv�`il Y � License No. ' <br /> Contractor DEST IJCT1 N ❑ <br /> NEW WELL ❑ LOIJJEWELL REPLACEMENT ❑ R ❑ <br /> TYPE OF WELL/PUMP: I SYSTEM REPAIR ❑EPTIC TANK Op LINE <br /> j PUMP INSTALLATION 16, <br /> 1 ER LINES t ITS/SUMPS` <br /> l DISTANCE TO NEAR <br /> :' � SEW —tT� �, <br /> Fp ATION _ter A RICULTURE WELL" <br /> TYPE O EL PROBLE AREA CONSTRUCTION SPECIFICATIONS Dia. f Well Casing <br /> r INTENDED USE ❑ Mante a Dia. of Well Excavation -. <br /> o Speci tions <br /> ❑ Industrial ❑ Open Bott <br /> ❑ <br /> ❑ Gravel Pack Tracy Type of Casing Type of tit <br /> '4 Domestic/Private ❑ Delta Depth of Grout Seal --� <br /> EJ Public ❑ Other <br /> ---Approx. Depth r ❑ Easter S ace eel In tolled byR <br /> ❑ irrigation a Work Done <br /> � H.P. <br /> { rWork Done ❑ Type of Pump �� <br /> Well Diameter <br /> Well Destruction ❑ �— <br /> l Filler Material {Below 501 <br /> Depth <br /> available within 200 feet.} <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REP IRIADDITION ❑ DESTRUCTION ❑ lNo septic system permitted if pubic sewer i <br /> Installation will serve: Residence Commercial Other <br /> h Number of living units: <br /> Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments <br /> 4 SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> r PKG. TREATMENT PLT.❑ Property Line—� <br /> Distance to nearest: ,1JJel Foundation <br /> r <br /> -Total lengthlsize <br /> LEACHING.LINE ❑ No. & Length of lines Property Line <br /> i <br /> FILTER BED ❑ Distance to nearest: ell Foundation <br /> Number <br /> ❑ Depth ' � ze _ <br /> SEEPAGE PITS ion Property Line <br /> SUMPS <br /> El Distance to nearest: ell Foundation { <br /> i ❑ <br /> l I hereby ceriify that I have prepared this application the the work will be done in accordance with San Joaquin county ordinances, -state laws, and <br /> DISPOSAL PONDS <br /> rules and regulations of the San Joaquin Local Health istr t. I cerfify that in the performance of the work for which this permit is issued, I shall not <br /> -contracting signature <br /> f Home owner or licensed agent's signature certifies the 1 ing: " of <br /> employ any person in such manner <br /> a n the perfomance toth wok for which this per I t!sissuedlfl shall emplora�p1ersonsisubject-A, workmaring or sub, n J,77 X,5 <br /> certifies the following:"I certify -� �t �7- /VQ 7i;"�""C ��S / <br /> ws of California." <br /> The appN-an ust all for all ui d spectio Comple drawing on r verse ide. Data: (�v <br /> + Title: <br /> f -Signed <br /> R DEPAR MENT USE ONLY g <br /> Area {'r <br /> � Date <br /> Application Accepted by Date <br /> Dat Final Inspection by <br /> Pit or Grout Inspection by <br /> —.� <br /> } Additional Comments: ❑ Manteca 823-7104 " ❑ Tracy 835-6385 3 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 <br /> I Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9520 <br /> _ a 1 <br /> CASH <br /> INFO RECEIVED BY. <br /> DATE PERMIT'NO." <br /> I FEE . AMOUNT DUE AMOUNT REMITTED <br /> + EH 13-24(REV.105) <br /> EH 14-28 <br />