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714 <br /> APPLICATION FOR PERMIT a <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> T ON AVE., STOCKTON, CA <br /> 1601 E. HAZEL <br /> Telephone 12091 466-6781, <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED :I <br /> (Complete in Triplicate) I <br /> application is <br /> and/or'install the work herein Regulations of the San Joaquin <br /> Application is hereby made to the SanCounul ordinance iNo.549 for sewage or Health District for a INo. 1862 foraweupump and the Rules and Regulations. f thThie <br /> made in compliance with San Joaquin � tY ���S. <br /> Local Health District. r /� PM <br /> t City of Sizef <br /> Job Addres l! <br /> Phone <br /> Address <br /> Owner's Name <br /> Address License No.��-� <br /> Phone <br /> IJ <br /> Conhactor WELL REPLACEMENT ❑ DESTRUCTION <br /> TYPE OF WELL/PUMP. NEW WELL OTHER ❑ <br /> SYSTEM REPAIR ❑ OP, LINE <br /> PUMP INSTALLATION ❑ SEWER LINES SE �--- DISPOSAL FLD. <br /> C �' <br /> DISTANCE TO NEAREST: SEPTIC TANK _�.-- OTHER PITS/SUMPS <br /> I FOUNDATION AGRICULTURE WELL <br /> TYPE OF; PROBLEM AREA CONSTRU ECIFICAT10N5 Dia, of Well Casing <br /> INTENDED USE ❑ Manteca of Well Excavation <br /> L3 industrial x Q Open Bottom Specifications <br /> Type of Casing <br /> ❑ Domestic/Private •❑ Gravel Pack Type of Grout <br /> Cl Other ❑ Delta Depth of Grout Seal <br /> I <br /> (1 Public Surface Seal installed by <br /> I i Irrigation pprox. Depth l I Eastern State Work Done (1 <br /> Repair Work Done <br /> Type of Pump H.P. �) <br /> Well De ion ❑ Well Diameter <br /> Sealing Material (top 50'1 <br /> Depth I Filler Material (Below 501 <br /> av200,feet.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t•] REPAIR/ADDITION l 1 DESTRUCTION INo ailable within septic system permitted if public sewer is <br /> Installation will serve: Residence w Commercial Other <br /> ��— <br /> 1 Number of living units: Number of bedrooms Water table depth l <br /> f Character of soil to aepth of 3 feet: Capacity No. Compartments <br /> SEPTIC TANK ah <br /> Method of Disposal <br /> PKG, TREATMENT PLT.❑ � <br /> Foundation _'Pro perty.Line <br /> Distance to nearest: Well { <br /> jTotal lengthlsize <br /> LEACHING LINE O No. & Length of lines property Line <br /> ❑ Distance to nearest: - Well Foundation <br /> f FILTER BED f <br /> I i DeQtti�_ Size Number <br /> SEEPAGE PITS <br /> ❑ Distance to nearest: Well Foundation/ Property Line <br /> _�--- <br /> I <br /> SUMPS L-1 <br /> DISPOSAL-PONDS ❑ II.. <br /> I hereby certify that I have prepared this application and that the work <br /> -wili_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 /> 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, I signature <br /> shalt not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contraceonsisub eat t waring or �kman's gcompensa- <br /> certifies the following: "I certify that in the performance of the work for which this permit issued, I shall employ p 1 <br /> tion laws of California." s <br /> - The applicant 't call for al equired spectio . Complete drawing on reverse side. Rr <br /> Date: <br /> Title:.••=.�. <br /> } Signed <br /> r <br /> FOR DEPARTMENT USE ONLY r { <br /> Date�94A f A <br /> Application Accepted by by <br /> Inspection to <br /> Pit or Grout Inspection <br /> Date. Final <br /> Additional Comments: ❑ Tracy 835-6385 <br /> ❑ Stk 466-6781 Cl Lodi 3693621 El Manteca 823 7104 Stk., CA 95.201 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O: Box 2009, <br /> �_. PERMIT•Np. <br /> FEE AMOUNT DUE MOUNT REMITTED ASR RECEIVED BY DATE <br /> INFO <br /> EH 13-24 IREv. <br /> -EH 14-26 -- <br />