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4 I� APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT h <br /> C� ' i ON AVE., STOCKTON, CA 11 <br /> 1601 E. HAZE. <br /> Telephone (209) 466-6781 9 �g�9 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,lAN <br /> (Complete in Triplicate) E1\iViROl�i(Vipf �A1 EALYH <br /> �Mreps>�y� rI�y(?6cation is <br /> Application is heieby made to the San Jaquin0 d calnHe No D5'49 for Sewage or permit <br /> No. 1862 for well/pump install <br /> nd the Rules and(Regulations of the San Joaquin <br /> made in compliance with San Joaquin County <br /> Local Health District. M i <br /> PM <br /> City tot Size l <br /> Job Address 4" 7 r 1f.Q <br /> 4ou <br /> Phone <br /> dress <br /> Owner's Name y r � <br /> r r ise No. �7 Phone r, <br /> Address ` <br /> G Intractar r. E ON ", <br /> i`NE ELL ❑ WELL REPLACEMENT ❑ _ - <br /> TYPE OF WELL/P P: I SYSTEM REPAIR ❑ HER ❑ <br /> PUMP INSTALLA ION D <br /> SEWER LINES �__� DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK _—�— OTHER WELLPITS/SUMPS <br /> FOUNDATION �— <br /> AGRICULTURE WELL .,. .. <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> i' INTENDED USE —- Dia. of Well Casing <br />! ❑ Industrial LlOpen Bkottom ElManteca Dia. of`Well Excavation Specifications <br /> ❑ TracyType of Casing <br /> ❑ Domestic/Private ❑ Gravel Pack . <br /> ( <br /> Depth of Grout Seal Type of Grout <br /> n Other !� P. Delta _ <br /> I'I Public Surface Seal Installed by <br /> IJ Irrigation _Approx. Depth i. I Eastern H.P. State Work Done _ <br /> Repair Work Done ❑ Type of Pkump � Sealing Material (top 50'1 <br /> Well Destruction IR Well Diameter <br /> Depth II /� Filler Material l8elow 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIRIADQ1T10N l ! DESTRUCTION I i aNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> f <br /> Installation will serve: Residence} Commercial_' Other�_---- <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: <br /> Capacity No. Compartments <br /> ! <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> P.KG. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well Foundation P V <br /> N <br /> ;i <br /> ! I Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Property Line <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> IN <br /> Number <br /> SEEPAGE <br /> SEEPAGE PITS I 1 Deptlh Size Property Line <br /> SUMPS Cl Dist ince to nearest: Well Foundation P y <br /> DISPOSAL PONDS <br /> 1 hereby certify that I have prepared this application and that the work will'be done in accordance with San Joaquin county ordinances-state laws;artd+�"l <br /> rules and regulations of the San Joaquin Local Health Di§trict. <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 subiect to workman's compensation laws of California." Contractto�nhiring ofsubjecto -cokman'scompensr <br /> CIS the following: "I certify th et in the performance of the work for which this permit is issued, !shall employ p <br /> tion laws of California." <br /> The applicant t 11 for Ip'edwnspectio plate drawing on reverse side. Date: <br /> _ p <br /> Title: Q <br /> 7. <br /> Signed X <br /> FOR DEPARTMENT USE ONLY <br /> ^ <br /> Date Area <br /> Application Accepted by <br /> Date _-._.--- Final Inspection by Date <br /> Pit or Grout Inspection by .�� <br /> Additional Comments: <br /> Stk 466-6781 ❑ Lodi '(,369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-M5 <br /> ❑ <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> CK RECEIVED BY GATE PERMIT'NO. 6 � <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH .:. <br /> INFO _V <br /> �` <br /> +-EH 13-241HEV.i/R5) <br /> EH 14-26 - - <br />