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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601,E.�,,HAZELTON-AVE., STOCKTON, CA i <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> ll the work herein <br /> .This <br /> cation is <br /> made in'com compliance with San Joaquin nJoaquin county ordinaHealth nce No.District49 for sewage or INo. 1862 for ell/pump and the Rules and Regulations of the Span Joaquin <br /> ma P , <br /> Local Health District. s- <br /> D <br /> t, city Loc size PM <br /> Job Address <br /> Owner's Name Address <br /> .. <br /> 1 c Phone <br /> a <br /> Contractor L >M Address License No. <br /> WELL <br /> TYPE OF WELL/PUMP: NEW WELL ❑ L REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION El REPAIR ❑ OTHER L1 <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PR09LEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> E3Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Q <br /> Specifications <br /> Type of SpecificationsDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Grout <br /> C1 Public Ll Other ❑ Delta Depth of Grout Seal Yp <br /> ❑ Irrigation ---Approx. D4:�O <br /> ter Surface Seal Installed by <br /> Repair Work Done [Type of PumpEH.P. ` State Work Done <br /> " 1Neil bestruction ❑ Well Diameter. �'- _ Sealing Material {top 50'} <br /> Depth -Filler.Material (Below 501 �. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic's st 200 frmiitted if public sewer is <br /> - .. installation will serve.- Residence —.Commercial - Other <br /> Number of living units: Number of bedrooms Water table deptFi <br /> Character of soil to a depth of 3 feet: <br /> Capacity No. Compartment�-E' <br /> SEPTIC TANK =❑ Type/Mfg, Method of ttt E <br /> PKG, TREATMENT PLT. ❑ property Line <br /> E Distance to nearest: Well Y Foundation/ N. <br /> i r <br /> Total length/size <br /> LEACHING LINE ❑ No. &Length of,lines Property Line ` <br /> FILTER eED k ❑ TD}s#ance to nearest:. Well Foundation ' <br /> rt,SEEeAGE-PITS+ ❑ .fDeptli{ Size <br /> Number <br /> *SUMPS O''�Distance to nearest: Well <br /> Foundation Property Line <br /> DISPOSAVPONDS ❑ + <br /> I hereby certify that-I have prepared this application and that the work will be done in accordance with San Joaquin 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 the work for which this permit is issued, I shall not <br /> employ any person in'such manner as to become subject to workman's compensation laws of California.".contractor's hiring or sub contracting signature <br /> certifies the owing: ertify that in the performance of the work for:,ch this rm" is issued, I shall employ persons subject to workman's compensa- <br /> 1. <br /> ° tion Iaws� f Calif0 nia-" -�- -� p �; ' <br /> The app(cant t fo all req 'ed i �il omp to drawing r side. <br /> Signed ; <br /> Title: u" ' " Date: I e� <br /> FOR DEPARTMENT USE ONLY <br /> pate Area <br /> Application Accepted n <br /> i / Date Final Inspection by Date <br /> Pit or`rout Inspect( I <br /> y <br /> Addition`+all"Comments:.- -'" <br /> ❑ Stk 466-6781 ❑ Lodi 369 3621 ❑ Manteca 823 7104 ❑ Tracy 835 6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE CK# RECEIVED BY DATE PERMIT'NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> + EH 13441REV.1/a5) f7 �� <br /> EH 1428 <br />