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I APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA 1� <br /> Telephone (209) 466.6781 <br /> I PERMIT EXPIRES 1 YEAR FROM DATEr:ISSUED � <br /> i . <br /> (Complete in Triplicate) f " <br /> Application is hereby made to the San Joaquin Local Health District for a <br /> made H compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 farwell/pump and the'Rules and Regulations of the San <br /> Permit to construct and/or install the work herein described f t e application is <br /> Loco( Health District..,r.t;.,:; <br /> t- Joaquin <br /> Job Address I <br /> City sv Lot Size PM <br /> Owner's Namer- �F r _ ? <br /> ►'t Address <br /> Phone �� p 17 <br /> Contractor �r <br /> dress 1��t�Q� u,yy� <br /> TYPE OF /PUMP.'- EW WELL ❑ W1 License No. Phone j <br /> PUMP INSTALLATION p WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> DISTANCE 70 NEAREST: SEPTIC TANKSYSTEM REPAIR ❑ OTHER El—� SEWER LINES ` DI n <br /> FOUNDATION AGRICULTURE PROP. LINE V <br /> INTENDED USE OTHER WELLPITS/SUMPS <br /> TYPE OF WELL PROS EA CONSTRUCTION SPECIFICATIONS n <br /> ❑ Industrial ❑ Open Bottom <br /> Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private ❑ Grave - — Dia, of Well Casing <br /> Ll Public ❑ Tracy .Type of Casing ` r x- Z' <br /> ther ❑ Delta Depth of Grout Sea! Specifications <br /> EJ Irrigation --Approx. Depth" "❑ EasYem T"� Type of Grout <br /> Repair W one ❑ T ` Surface Sea( Installed by <br /> Type of Pump H.P. r <br /> Well Destruction ❑ Well Diameter -�� I State Work Done <br /> Seating Material ftop 50') <br /> Depth } Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW lNSTALLA7lON ❑ REPAIR DDI ❑ DESTRUC7l0 (No septic system permitted if public sewer is <br /> j II <br /> Installation will see <br /> 3"Residence available within 200 feet.) <br /> Commercial Other <br /> Number of living units:I (Number'of bedrooms <br /> Character of soil to'a depth of 31 feet: <br /> SEPTIC TANK ,(� ❑ Typ6lMfg Water table depth <br /> PKG. TREATMENT PLT. ❑ ! Capacity. No. Compartments <br /> ` Method Of Disposal <br /> ' <br /> Distance to nearest: Wel( � <br /> Foundation Property Line <br /> LEACHING LINE �❑ No.i& Length of lines <br /> FILTER BED ❑ Distance to nearest: Well Total length/size <br /> I [ Foundation Property Line <br /> SEEPAGE PITS IDDepth M Size <br /> SUMPS -Number —� <br /> ❑ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS C1 ' Property Line <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 certi <br /> employ any person in such manfier as-to become-subject fy that in the performance of the work for which this permit is issued, I shall not <br /> .to workmari's.compensation.laws of California.'-Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this - <br /> tion laws of California." Permit is issued, I shalt employ persons subject to workman's compensa- <br /> The a licant mut for all required inspections.._Complete-drawing on ' <br /> rse.side._ <br /> igned Title: _ /f <br /> Date: <br /> FOR bEPARTMENT USE ONLY <br /> Application Accepted by �l O r,y <br /> Date l j� ! Area <br /> Pit or Grout Inspection pate <br /> Final Inspection by Dateg �3A7 <br /> Additional Comments:F 1 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 i <br /> ❑ Monte 8�3-7104 ❑ 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 /> INFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BY pgTEII <br /> PERMIT`NO. j <br /> + EH 13-241REV.1/8s} <br /> EH 1426 <br />