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r?" APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �r 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 1209? 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> all the work <br /> cation is <br /> Application is hereby made to the San Jootaq ui O�dinalncfe No.549 for sewage or ealth District for a permitNo. <br /> 1862 for cwell/pump at and/or nd the R l s and hereindescribed, <br /> of the San Joaquin <br /> made in compliance with San Joaquin C ty <br /> Local Health District. t <br /> City �7-441' Lot Size PM <br /> Job Address �` <br /> Phone' e" <15 <br /> Owner's Name Address <br /> f/ �p 6-1-- License No. Phone <br /> Contractor �L Address ; <br /> OWELL/PUMP: NEW WELL I] WELL REPLACEMENT ❑ DESTRUCTION LJ <br /> TYPE <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER El <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. P. LINE I <br /> FOUNDATION AGRICULTURE WELL. 0 LL PITS/SUMPS <br /> PROBLEM AREA CO TION SPECIFI <br /> 11 <br /> INTENDED E Dia. of We `C�sin3- <br /> 0 <br /> Industrial ❑ Open Bottom ❑ Mantec Dia. of Well Excavation <br /> racy Type of Casing Specifications <br /> 0 Domestic/Private ❑ Gravel Pack Type of Grout <br /> {l public n Other ❑ Delta Depth of Grout Seal <br /> I I Irrigation pprox Depth l i Eastern Surface Seal Installii { <br /> ` H P State Work Done <br /> Repair Work Don Type of Pump <br /> Well D ion ❑ Well Diameter Sealing Material (top 5D') <br /> i <br /> Depth I Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION la REPAIRlADDlTIDN I.! DESTRUCTION availableiwthin 20stem 0 feetpermitted if public sewer is <br /> IF <br /> Installation will serve: Residence J Commercial _ Other <br /> Number of living units: Number of bedrooms <br /> i Water table depth <br /> Character of soil to a depth of 3 feet: <br /> ` No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg CapacityMethod of Disposal <br /> PKG. TREAT ENT PLT. ❑ <br /> nce to nearest: Well Foundation Property Line <br /> r <br /> + otaI length/size <br /> LEACHING LINE Cl Na. & Length of lines <br /> FILTER BED ❑ Distance to nearest: Well oundation-.- _ <br /> rt Line <br /> t - <br /> a SEEPAGE PITS i I Depth Size Number �f <br /> SUMPS istance to nearest : Well Foundation Property Line <br /> DiSPO DS ❑ <br /> Thereby 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 /> Id <br /> rules and regulations of the San Joaquin Local Health District. <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, l shall not <br /> ring or <br /> signature <br /> employ any person in such manner as to become subject to workman's compensation law s of California.'"Contraceonsisub'ect t wo�kmanls sub-contracting <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ p 1 <br /> tion laws of California." I( <br /> The applicant m s II for all required ' spections. Complete drawing an reverse side. <br /> Signed X <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY �J f <br /> Date V' Area <br /> 'l Application Accepted by <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date <br /> Additional Comments: r"" <br /> l ❑ Stk 466-6781 1:1 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Permit/services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> Applicant - Return all copies to: Environmental Health ►►"" <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE gPERMIT'NO]- <br /> C <br /> INFO <br /> a EH 13-24(REV.)/n51 <br /> EH 14-28 <br />