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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �pcm <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> /or install the work <br /> n described. This <br /> cation is <br /> made in compliance with Sanade toJoaqu nthe SanCounty O d naJoaquin Localnce No.549 for sewage Health District for a or INo 1862 for t to cwell/pump and the Rules and'R Regulations of the San l Joaquin <br /> Local Health District. <br /> Job Address City oeA) Lot Size PM <br /> f <br /> Vk <br /> Owner's Name <br /> ��/l j�je/1�1Q17/ Address $7/3-3 /'7 L)L-,&L Phone I-S'L <br /> Contractor <br /> 6'.G. Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUOCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOS PROP. LINE <br /> FOUNDATION AGRICULTURE WELLHER WELL PITS/SUMPS i <br /> INTENDED USE TYPE OF WELL PRrp <br /> UCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ . of Well Excavation <br /> Dia. of Well Casing <br /> e of Casing Specifications W <br /> ❑ Domestic/Private ❑ Gravel Pack g Type of Grout — <br /> M Public i7 Ll pth of Grout Seal <br /> I I Irrigation __Approx. Depth I I rface Seal Installed by <br /> Repair one ❑ Type of Pump State Work Done <br /> Well Destruction ❑ Well Diameter g rial (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION (No septic system <br /> in permitted if public sewer is <br /> availabInstallation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> 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 /> rules and regulations of the San Joaquin Local Health District. <br /> 1 certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: " <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: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must da I r all require i pectiAns. Complete drawing on reverses side.. <br /> Signed X Title:/"U� Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date " v� Area <br /> Pit or Grout Inspectiony Date Final Inspection by Da <br /> Additional Comments: <br /> ©S ' <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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> ♦ EH 13-24(REV.iiH5) 2- <br /> ; sC'o 302 �`�-`�� n-22 <br /> EH 14-26 <br />