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' APPLICATION ION FOR PERMIT <br /> # <br /> t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT j <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> F Telephone (209) 466-6781 <br /> i1 PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> a application is <br /> Health District for a permit to construct and/or install the work herein described. This ap l Joaquin <br /> oa urn Local H Regulations of the 5 <br /> Application is hereby made to the San J 4 <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or Nn. 16&2 for well/pump and the Rules and <br /> Local Health District. A PR f <br /> Qt, ' <br /> 1 -7 I P�{l t-0, 14 City ,Sr� _ Lot Size x � PM <br /> Job Address �Inh <br /> ��U L W � Di� Address M Phone <br /> 'Owner's Name _F <br /> Address Lice :. - one <br /> 1' Contractor <br /> NEW WELL ❑ WELL REPLACEMENT:❑-' DESTRUCTION t <br /> TYPE OF WELL/PUMP: kiER_' <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR <br /> FLD. PROP. LINE <br /> r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSALPITS/SUMPS <br /> { FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> pia. of Well Casing <br /> - Type of Casing Specifications <br /> EJ Domestic/Private ❑ Gravel Pack CI-Tfacy -•- i 9 <br /> Other fl Type of Grout F <br /> F1 Public Delta Depth of Grout Seal <br /> I I Irrigation �._Approx. Depth l I Eastern t. f SurfaceSeal Installed by <br /> k.Repair Work Dane Ll Type of Pump "FI.P.` ' State Work Done— <br /> s , <br /> t Well Destruction Well Diam ter - Sealing Material Itop 501 <br /> Depth Filler Material Melow 50'1 <br /> TYPE OF SEPTIC WORK: NEW <br /> A-t-ATION-1-1-' -REPAIWADDITION F 1F DESTRUCTION t I a�ailabPelwithin 200 feetit�ed if public sewer is <br /> Installation will serve: Residence_' Commercial, Other f <br /> rNumber of living units: Number of bedrooms .`•,. 9 Water table,depth- <br /> Character of soil to a depth of 3 fest: i r <br /> SEPTIC TANK ElType/Mfg ' Capacity NoI Compartments <br /> t Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> i <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 171No. & Length of lines Total lengthlslze <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line u <br /> *I <br /> SEEPAGE PITS I 1 Depth1 Size Number <br /> SUMPS D 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 Joquin 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, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, l shad employ persons subject to workman's compensa- <br /> I tion laws of California." I <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> f <br /> igned X W ' 1 Title: W)Q1F Date: <br /> �-S <br /> \ FOR DEPARTMENT USE ONLY <br /> Date �t Area <br /> Application Accepted by <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date ' <br /> I Additional Comments: <br /> ❑ Stk 466-6781. ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant-.Return all copies to: En�ironmentel Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE CK RECEIVED BY DATE PERMIT NO, <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH f7+ EH 13-241REV.)/R5) <br /> EH 14-2d <br />