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I'f APPLICATION FOR PERMIT <br /> ft SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> } PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Ih District for a the work <br /> describe . Tis <br /> is <br /> here <br /> cation <br /> Application is hereby made to the San`Joui oclHNto. 549 for sewage or't to No. 1662 forcwekl/pump aand/ortnd the Rules and IR gulations of the Sanl Joaquin <br /> County made in compliance with San Joaquin Ca ty Ordinance <br /> Local Health District. t}! <br /> 3 r City Lot Size PM <br /> Job Address <br /> Address m Phone <br /> Owner's Name x Cyt <br /> i Contractor <br /> Address t0 License No. Phone <br /> ■ -NEW'WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION`❑ „ <br /> TYPE OF WELL/PUMP:r „j.. * r OTHER ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLQ- PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS y] <br /> 4 <br /> INTENDED USE TYPE OF-WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of:Groul <br /> ng <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of.Well Excavation <br /> Type of CasingSpecific <br /> O Domestic/Private ❑ Gravel,Pack ❑ Tracy Yp Type of — <br /> f l 1 Public ❑ Other �1 n Delta Depth of Grout Seal r <br /> I I irrigation _-Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Weil Diameter Sealing Material (top 50'1___. _- <br /> Depth r� r.Filier Material (Below 501 w <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION {'l REPAIR/ADDITION t I DESTRUCTION availsepti cyst m permitted if public sewer is <br /> eet <br /> Installation will serve: Residence'L-� ommercial_ Other <br /> ,i <br /> I 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 /> ' Method of Disposal <br /> PKG. TREATMENT PLT. ❑ , <br /> r Distance to nearest: Well Foundation . Property Line <br /> LEACHING LINE ❑ No. &tLength of lines Notal length/size <br /> FILTER BED E] Distance to nearest: Well Foundation Property tine <br /> 1I Size <br /> SEEPAGE PITS l } Depth' <br /> Number <br /> rPro art Line <br /> SUMPS Ll Distance to nearest: Well Foundation P 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. I <br /> me owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> amp any person in manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies t ollowing: "I ce 'fy 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 ornia." <br /> t <br /> e applican mus all for all r quir ins tion )eta drawing- avers <br /> =;j5 <br /> Signed Title: <br /> Date: <br /> l FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> � Date '— Area <br /> 3. Qate Final Inspection by <br /> Date <br /> Pit or Grout Inspection-by <br /> Additional Comments: _ <br /> Stk 466-fi781 ❑ Lodj 359 3621 L7 Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 <br /> 1 _J FEEAMOUNt DUE AMOUNT REMITTED,, CASH RECEIVED BY DATE PERMIT'NO. <br /> )NFO <br /> + EH 13-241REV.iik51 <br /> EH 14-20 <br />