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APPLICATION FOR PERMIT a <br />'. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> I", Telephone (209) 466-6781 <br /> ` PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> to construct Application is hereby made to the San Joaquin Local <br /> Health <br /> Dis trict for sewag <br /> made in compliance we or permit and/or herein <br /> or a No. 1862 for wefl/pump and fie Rules and Regulations of the application <br /> Joaquin <br /> San <br /> San Joaquin County Ordinance-No. <br /> Local Health District.' , :b 9e7- <br /> (/�{ •City G Lot Size — PM <br /> Job Address <br /> FM, <br /> _ — Phone <br /> Owner's Name <br /> G d j• Address s e rrrn ti - <br /> h. �.� Phone <br /> ' Address i� 1 License No. <br /> Contractor <br /> ❑ DESTRUCTION <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C1 <br /> SYSTEM REPAIR ❑ OTHER El <br /> PUMP INSTALLATION ❑ '.. DISPOSAL FLD: PROP. LINE ' <br /> SEWER LINES _1 ` ' PITS/SUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK: AGRICULTURE WELL OTHER WELL- <br /> i FOUNDATION <br /> ------------------ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing i <br /> f: <br /> 1 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation❑ Industrial _ Specifications <br /> Type of Casing <br /> f p Domestic/Private [I Gravel Pack ElTracy, Depth of Grout Seal Type of Grout <br /> ❑ Other ❑ Delta` � ;-'; � 4 <br /> ❑ Public Surface Seal Installed by <br /> Q irrigation �4pprox.,Depth ❑ Eastern <br /> H P State Work Done <br /> x r "Repair Work Done ❑ Type of Pump - <br /> ' ' -4 Sealing Material (top 50') A ~ '� '�— <br /> L =s= Well Destruction ❑ tWell Diameter,, g 1� <br /> pw ., <br /> Depth. a Filler Material (Below 501 s <br /> r <br /> TYPE OF SEPTIC WORK:: NEW INSTALLATION �REPAIRlADDlT10N ❑ DESTRUCT l0�❑�aNailabpe+witsetc hin 200 perm if public sewer is,.) <br /> I Installation will serve: Residence ;":Commercial— Other�,,,�,,- , <br /> Number of living units: '' } Number of bedros ` t <br /> + table depth <br /> Water Character of soil to a depth of 3 feet: <br /> CJ <br /> t'gft <br /> �g' Capacity l - Db No. Compartrrents <br /> SEPTIC TANK Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. 0 <br /> Foundation <br /> -- Property Line <br /> l� on <br /> Distance to nearest: A Well�- , <br /> . 'Total length'Isiie <br /> LEACHING LINE -No. & Length of lines —� , <br /> ` Foundation Property Line y <br /> FILTER BED Q Distance to nearest: Well— fin -��'— <br /> [ Number G f <br /> SEEPAGE PITS .� Depth Size <br /> ' _ __ Property Line -- 2 <br /> I SUMPS d', Distance to nearest: Well -� Foundation <br /> " '-''*- <br /> DISPOSAL PONDS ❑ s. <br /> hereby certify that I have prepared this application and that the work will done in.accvrdance with San Joaquin county ordinances;estate laws,and <br /> rules and regulations of the San Joaquin Local Health District.' 4 '+ <br /> .',. <br /> j Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I signature <br /> shag not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's shin or u wo ntracti aompensa <br /> certifies the following:"1 certify that in the performance of the work for which this permit 1sssued,l shall employ persons <br /> tion laws of California. $ i <br /> The applicant must call fo'r all required inspections. Complete drawing on reverse side. l I t <br /> ®,� Title: <br /> Date: <br /> i Signed .KdF ` ' - r <br /> ' DEPARTMENT USE ONLY <br /> ,.. Date jArea, <br /> —� .. <br /> Application Accepted by Date <br /> I- ... Y <br /> Pit or Grout Inspection by <br /> Date �� Final Inspection by i <br /> Additional Comments; r + <br /> Q Stk 466-Ml ❑ Lodi 369-3621 LlManteca 823-7104 ❑ Tracy 8354M <br /> P.O,..., , <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., Box 2009, Stk., CA 95201 r t <br /> CK DATE PERMIT'N0. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH t RECEIVED BY <br /> INFO _ __ r <br /> —3$ <br /> + EH 13-24(REV.1 <br /> SH 14-26 l <br />