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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) scribed. This <br /> mcation is <br /> ade <br /> in on is lance meds oJoaquin County Ordinance lHealth No.549 for sewage or permit <br /> Nop 1862 forconstruct <br /> well/pump and the Rules and herein <br /> R gulations of the San"Joaquin <br /> made in compliance with San <br /> Local Health District. <br /> �►– �Q � � �+)-- City 0 PJ Lot Size PM <br /> Job Address <br /> • Phone <br /> Owner's Name /.O 1 N Address <br /> r� Phone�y�``'j�a <br /> S�L>� Address L x ���rw ���aicense No, <br /> I Contractor —.— DESTRUCTION 0 <br /> TYPE OF ELL/PUMP: NEW.WELL ❑ WELL REPLACEMENT <br /> SYSTEM REPAIR ❑ O <br /> PUMP INSTALLATION ❑ PROP. LINE <br /> DISTANCE TO NEA T: SEPTIC TANK <br /> SEWER LINES DISPO <br /> NDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE 0 ELL PROBLEM A NSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> I' ❑ Oen Bottom anteca Dia. of Well Excavation <br /> El P "specifications <br /> Type of Casing <br /> ❑ DomesticlPrivate t❑ Gr c Depth of Grout Seal Type of Grout <br /> ❑ Public � Other ❑ Delta rR <br /> IApprox. Depth l I Eastern Seal installed by I <br /> I I Irrigat State Work Done <br /> Repair Work Done ❑ Type of Pump H.P. f <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 11V' <br /> Depth Filler Material (Below 501 perm I tr <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTFt C {vailNo septic syste <br /> able within 200 feet.) <br /> Installation <br /> public sewer is <br /> 1 <br /> Installation will serve: Residence, Commercial— Other <br /> !Number of living units: Number of bedrooms WaAde " 1Character of soil to a depth of 3 feet: Na.SEPTIC TANK Type/Mfg CapacityMePKG. TREATMENT PLT. ❑ property Distance to nearest: 'WeH � FoundationTotal length/size -- <br /> LEACHING LINE ❑ No. & Length of lines pro ert FILTER BED ❑ Distance to nearest: Well Foundation P YSizeNumber <br /> SEEPAGE PITS I i Depth pro ert SUMPS ❑ Distance to nearest: Well Foundation P YDISPOSAL PONDS ❑l hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquncouyrdinances, state laws, and <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 1.the work for whi9h this permit is issued, !shall not <br /> employ any person in such manner n to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> 1 certifies the fallowing: "I certify 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 California." <br /> The applicant must call for all rqquired inspections. Complete drawing on reverse side, <br /> Signed X Title: <br /> pate: <br /> FOR DEPARTMENT USE ONLY <br /> Date / Area <br /> t Application Accepted by y <br /> Date Final Inspection by Date <br /> Pit or Grout inspection ,G�/ <br /> Additional Comments: (� <br /> I ❑ Stk 466-87$1 ❑ Lodi 369-3621 ❑ Manteca 823-7104 EI Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Sax 2009, Stk., CA 95201 <br /> I <br /> y FEE CK RECEIVED BYEDATE PERMIT NO. <br /> f AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> 1. + EH 13-24 IRE7+.i�e 51 <br /> Com- � <br /> EH 14-28 <br />