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J APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT r <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 /> .This <br /> Application is hereby maation is <br /> de to the San Joaquin Local <br /> He lth District <br /> for sewage ar it to 1862construct <br /> and/or install d he Rulep <br /> es and'Reg�tions Of the SanrcJooaqu n <br /> made in compliance with San Joaquin County <br /> Local Health District. " 's1i. <br /> - City <br /> Size PM <br /> II _ <br /> Job Address <br /> _ Phone <br /> Address — <br /> �Owner's Names <br /> Contracto ! Address <br /> License No. 0 Phone <br /> N WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Q <br /> TYPE OF WELLIPUMP' SYSTEM REPAIR ❑ OTHER ❑ �J <br /> PUMP INSTALLATION ❑ v 4 <br /> SEWER LINES DISPOSAL FLD. PROP. LINE .J5 <br /> DISTANCE TO NEAREST:.SEPTIC TANK OTHER WELL PITS/SUMPS <br /> ` FOUNDATION �-- AGRICULTURE WELL <br /> I <br /> INTENDED USE TYPE OF WELL' PROBLEM AREA,' ia <br /> ti CONSTRUCTION SPECIFICATIONS D of Well Casing <br /> '❑ Open Bottom ❑ Manteca Dia.,of Well Excavation <br /> 3 Q Industrial Specifications <br /> ❑ Gravel Pack ❑ Tracy Type of Casing <br /> ❑ Domestic/Private ''� Depth of`Grout Seal Type of Grout <br /> ' Q other - ❑ Delta !' <br /> ❑ Public w, f <br /> ---Approx. Depth ❑ Eastern Surface Seai Instal, by <br /> Q Irrigation State Work Done <br /> Repair Work Done ❑ Type of Pump _ H.P. <br /> / Sealing Material,(top 501 <br /> Well.Destruction ❑ Well Diameter r FilierlI aterial (Below 50') <br /> I Depth <br /> available within 2_00 feet,)' <br /> TYPE OF SEPTIC WO11 RK: NEW INSTALLATIOR ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if.public sewer is <br /> Installation will serve: Residence Commercial Other — WwT <br /> Number of bedrooms <br /> Number of living units-.4— i. r' Water table depth <br /> _ <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> ❑ Type/Mfg Capacity�� <br /> SEPTIC TANK Method of Disposal <br /> { PKG. TREATMENT PLT. ❑ <br /> Foundation Property Line <br /> ! Distance to nearest: Well Y�r <br /> � � Total length/size � <br /> LEACHING LINE W�'No• & Length of lines —l�, _.�_ r Line Le <br /> Y� -� Foundation +�— Property <br /> FILTER BED ❑ Distance td nearest: Well _ i <br /> M <br /> til 5....w�.w."r""'°S11'e...+. .- - - WEU I n eD r <br /> SEEPAGE PITS �-Oap G' y s=„ ' A Foundationt Property Line r <br /> SUMPS 13 Distance td.nearest: Well; �"'-- — <br /> D15POSAL PONDS <br /> t I hereby certify that 1 have prepared this application and that the work will be done iri accordance with'.San <br /> an Joaquin county ordinan�e�s�state laws, <br /> rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signaturel not <br /> 'certifies the follo winogcmlacer�that sjt�n lawoof California."Contractor's lhir ng othis Psub-cont acting signature <br /> employemploy any person in such manner as to become"subject to <br /> } <br /> - certifies the following: "I certify that in the performa�ce of.'��work for which this permit is issued,I shall employ persons sutiject to workman's compensa- <br /> tion laws of California.' <br /> The applica ust call for all req jr d ins ctions plate drawing an reverse side. <br /> 'Rate: <br /> Title: <br /> Signed a <br /> 41 FOR DEPA ENT USE ONLY v <br /> Date`— Are <br /> Application Accepted by `.� Date 7 <br /> 'Date��S'.;� Final Inspection by i; <br /> Pit or Grout Inspection by <br /> i <br /> s , <br /> Additional Comments: Tracy 835-M I <br /> ❑ Stk 4664M1 ❑i Lodi 369-362mentai Hp IhePermit/Snteca �e;rv�aes 1601 EpHazeltan AP.O. Boz 2009, Stk., CA 95201 <br /> Applicant Return all cop <br /> CK RECEIVED BY DATE PERMIT''NO. <br /> FEERAMEOUNTUE AMOUNT REMITTED CASH <br /> INFO l} <br /> + EH 13-24(REV.1/65) <br /> EH 14-26 <br />