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ru;39 CS <br /> APPLICATION FOR PERMIT �/ " <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT Hp W (/ <br /> 1601 E. HAZELTON AVE., STOCKTON, CA Qx , n <br /> Telephone (209) 466-6781 AAA <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> n described.This <br /> cation is <br /> all the work <br /> Application is hereby with <br /> anoJoa u n County Ordinance Local <br /> No.District <br /> 549 for sewage or permit <br /> No. 1862 for well/and/or <br /> pump and the Rules and IR gulations of the San'Joaquin <br /> made in compliance with S q <br /> Local Health District. J 4 Al—FQ,, <br /> ( <br /> City p of Size PM <br /> Job Address <br /> Phone <br /> ^Address <br /> Owner's Name <br /> Contractor Address <br /> License No. Phone <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El <br /> SYSTEM REPAIR ❑ OTHER <br /> PUMP INSTALLATION ❑ DISPOSAL F PROP. LINE <br /> SEWER LINES A <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL WELL PITS/SUMPS <br /> FOUNDATION <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CON5 ION SPECIFICATIONS Dia. of Well Casing <br /> E3 Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Specifications �^ <br /> Type of Casing �) <br /> El Domestic/Private ❑ Gravel Pack ❑ Tr Depth of Grout Seal Type of Grout <br /> ❑ Public ❑ OtAppir <br /> er Delta <br /> ❑ Irrigation _ epth 11 Eastern Surface Seal Installed by <br /> H.P. State Work Done_ <br /> Repair Work Done ❑ T of Pump Sealing Material (top 50'1 <br /> Well Destruction Well Diameter <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION El REPAIR/ADDITION ❑ DESTRUCTION availableNo 'within 200 feet.)if public sewer is <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal d <br /> PKG. TREATMENT PLT. ❑ Foundation Property Line <br /> Distance to nearest: Well <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Foundation Property Line <br /> FILTER BED ❑ Distance to nearest: Well <br /> SEEPAGE PITS ❑ Depth <br /> Size Number <br /> SUMPS ElDistance to nearest: Well Foundation Property Line y <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. at in the g work for th <br /> d, I shall not <br /> Home owner or licensed n such manner to become subject workman's <br /> rtcompensation lawsoof California."Contractor's'hir ng'orr sub-contracting rmit is signature <br /> employ any personpersons subject to workman's compensa <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. ;( t i <br /> Date: 4 C1 <br /> Signed <br /> ORD PARTMENT USE ONLY <br /> a <br /> re <br /> Date AEy <br /> Application Accepted by Dat <br /> Pit or Grout Inspection by <br /> Date_---- Final Inspection by o <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Man 823 7104 ❑ Tracy 835 6385 Stk., CA 95201 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, <br /> CK RECEIVED BY DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> + EH 13-24(REV.1/e 5) , ,0 1 3 S E no <br /> EH 14-26 <br />