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APPLICATION FOR PERMIT <br /> SAN JOAOUIN'LOCAL°HEALTH DISTRICT <br /> 1601E HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-5181 <br /> f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 4� Me,.y 1. (Complete in Triplicate) application <br /> /or install the <br /> Application is hereby made to the San JoaquinOrdinance <br /> d nanceallo.Districtith 549 for sewage or permit <br /> 1862 for cwell/pump and the Rules and work-herein <br /> ations of the ribed.This Joaquin <br /> made in compliance with San Joaquin County F J y <br /> i Local Health District. a,.•' 't <br /> pv DA_ _AIDC CityC�7ad/i! Lot Size ' <br /> � 00 PM <br /> I Job Address <br /> _. O*}-� _ Phone <br /> •Qn�A�f � Address <br /> Owner's Name a` -1-� <br /> f ES r °� License No. 'one <br /> Address °7 ` r <br /> k Contractor. WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> Y TYPE OF WELLI UMP: NEW WELL ❑ R OTHER ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> SEWER LINES �� DISPOSAL FLD. i PROP. LINE <br /> k DISTANCE TO NEAREST: SEPTIC TANK — OTHER WELL— <br /> FOUNDATION <br /> - FOUNDATION .��— AGRICULTURE WELL I <br /> i TYPE OF WELL PRO13LEM AREA CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE �— Dia. of Well Casing <br /> ❑ Open Bottom Cl Manteca Dia:of Well Excavation <br /> ❑ Industrial Specifications <br /> ❑ Tracy Type of Casing <br /> ❑ Domestic/Private ❑ Gravel Pack D Depth of Grout Seal Type of Grout <br /> ❑ Other ❑!Delta <br /> ❑ Public Surface Seal Installed by <br /> H.P. <br /> ► ❑ Irrigation t �pprox. Depth ❑ Eastern State Work Done <br /> ' <br /> Repair Work Done D Type of Pump ; <br /> Sealing Material ttop 501 <br /> Well Destruction ❑ Well Diameter Filler Material {Below 501 <br /> Depth <br /> f available within 200 feet.tpubl,�c, <br /> TYPE OF SEPTIC WORK NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION Mo septic system permier is <br /> 9 Other <br /> r Installation will serve: Residence Commercial Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. CompartmentCapacity SEPTIC TANK ❑ TypelMfg Method of Dispos <br /> PKG. TREATMENT PLT. ❑ f Foundation Property Line <br /> Distance to nearest: Well <br /> F <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Foundation Property Line <br /> FILTER BED 71 Distance to nearest:' Well fi <br /> [ Number <br /> SEEPAGE PITS ❑ Depth — Size <br /> SUMPS ❑ Distance to nearest:' Well <br /> Foundation Property Line <br /> E� j <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the wok will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. this pe6it is <br /> Home owner or licensed agent' Sig <br /> i ure <br /> as to become subjectlto workman's lowing: "I rtcompensation lify that in the aews of California."Contract r's�hir ng or sub-cont shall not <br /> act nglsigne sa- <br /> employ any person in such <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,I sfia11 employ persons subject to workman s campen - <br /> tion Yaws of California." <br /> l The applicant II for all r fqu inspection Complete drawing on reverse side. �. <br /> Date: <br /> Title: <br /> Signed <br /> FOR DEPARTMENT-USE ONLY <br /> Area �. ._ <br /> ,�,.� Date <br /> Application Accepted by Date <br /> Date <br /> Pit or Grout Inspection <br /> �— Final Inspection by / <br /> Additional Comments: ❑ Trac 835-6385 <br /> [3 Stk 466-6781 ❑ Lodi 369-3621 ❑Manteca 7104 Y Stk., CA 95201 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,00/ <br /> K RECEIVED BY DATE PERMIT"NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CA H <br /> INFO <br /> + EH 13-24(REV.1185) `��` C70 <br /> - EH 14-2e - - <br />