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r APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> k <br /> f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> fDistrict for a <br /> Applicaticompliance maith a to the San Cou Joaquin <br /> ty Ordinance cllNo. 549 for sewage or permit <br /> No. 1862 for cweii/pumlp atnd the Rules and hereinR Regulations of the San'J aqca ion is <br /> uin <br /> made <br /> Local Health District. <br /> i City Lot Size PM <br /> Job Address <br /> Address Phone <br /> Owner's Name _ ,, ff <br /> : Contractor Address <br /> 3 Q x L License No.`-I 3 D��.Q Phone �� <br /> F TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION El <br /> -..-"„--.,,+---:--�.-._.�-^-^�"-."-PUMP'INSTAL'L".ATION�'❑ <br /> SYSTEM-REPAIR--❑--'"""""'"--OTHER-E1 <br /> k DISPOSAL FLD. PROP. LINE <br /> i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - Dia.-of_Well.Casin <br /> '�^'-""❑-Industrial <br /> x.�-•.�-• ❑`Open-Bottom----�-�O-Manteca«»-_..�.�,rDia"of-Well-Excavation- - -- g"-- <br /> Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack D Tracy Type of Casing T e of Grout <br /> M Public CI Other D Delta Depth of Grout Seal YP <br /> I I Irrigation Approx. Depth t I Eastern Surface Seal Installed by <br /> Repair Work Done` ❑ ,r1h,Type of Pump H.P. State Work Done <br /> Well Destruction CI Well Diameter Sealing Material (top 50') <br /> ' -4,11-1 Depth _FillerYMateri,31_(Below 50'.). -- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION i TRUCTION I I (No septic system <br /> thin m Permifeet.tted if public sewer is <br /> s <br /> Installation will serve: Res dence F Commercial_ Other <br /> Number of living units: 7 Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> I SEPTIC TANK l� Type/Mfg Capacity = No. Compartments <br /> � Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> + Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE moo. & Length of lines. V l Total length/':!i a <br /> FILTER BED ❑ -- Distance to nearest: Well Foundation VU Property Line <br /> SEEPAGE PITS .�L__.Bepth Size Nu bar <br /> per Property Line <br /> I SUMPS t 0 Distance"to nearest: Well Foundation <br /> i DISPOSAL PONDS ❑ <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 /> G 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, 1 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 following:." ertify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> f o s of Galifornia. <br /> The applic ust II r all qu d ins ctio ' . mp a drawing on r rse side. <br /> Title. Da <br /> Signe te: <br /> R P MENT USE ONLY f <br /> Date Area <br /> Application Accepted�by <br /> r <br /> Pit or Grout Inspectionnbby e" Date Final Inspection by / Data 1 G� <br /> Additional Comments: <br /> E3 Stk 466-6781 fl Lodi 369-3621 CIManteca 623-7104 ElTracy 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 AMOUNT DUE , AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'ND. <br /> INFO <br /> +,EH13-241REV.i <br /> �— <br /> i <br /> EH 14-2s ' <br />