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APPLICATION FOR PERMIT <br /> 1' <br /> SAN�JOAQUIfT LOCAI_-HEALT.H DISTRICT <br /> r Er­HAZEL <br /> TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> . . . , <br /> ~� (Complete in Triplicate) <br /> I Application is hereby made°to the San 3Joaquin Local Health District for aper <br /> mit to c <br /> onstrumade in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 forcwell plump atnd all the Rules and Regulations of the Santhe work herein described. This ap 'Joaquiis <br /> n <br /> Local Health District. <br /> Job Address �� <br /> City Lot Size/4W ��© PM <br /> Owner's Name <br /> Phone v ' <br /> Contractor �. %X <br /> C <br /> Address r License;a�o. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ --��._Phone_ <br /> WELL REPLACEMENT ❑ DESTRUCTION.,❑._ <br /> PUMP INSTAL TION ❑" S STEM REPAIR ❑' <br /> DISTANCE TO NEAREST: SEPTIC TANK � � OTHER ED <br /> SEWER LIN DISPOSAL FLD. PROP LINE r. <br /> z FOUNDATION AGRICUL RE WELL OTHER WELL <br /> 1 PITS/SUMPS <br /> INTENDED USE TYPE OF WELL ROBLEM A A CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ antec .N,- ;, �^ <br /> Dia. of Well Excavation r Dia. of Well".Casing _ 1 <br /> D Domestic/Private ❑ Gravel Pack D Tr ,,t <br /> 1"1 Public TYPe of Casing Specifications) + <br /> !:l Other Cl to Depth of Grout Seal t <br /> I I Irrigation !_Approx:iDepth I Eastern Type-of Grout + <br /> Repair Work Done ❑ T Surface Seal Installed by +` <br /> Type of Pump; H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 50'1 r <br /> Depth f Filler Material Welow 501 <br /> TYPE OF-SEPTIC WORK: NEW INSTALLATIONf REPAIR/ADDITION l-1 DESTRUCTION I <br /> 1 2 r No septic system permitted if public sewer is 3 , <br /> Installation will serve: Residence XO Commercialevailable within 200 feet) <br /> Qther Ef. <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> ' table depth i <br /> SEPTIC TANK ❑ Type/Mfg Water� !I <br /> PKG. TREATMENT PLT. ❑ Capacity--.. No. Compartments <br /> Method of Disposal it <br /> .�r Distance to.nearest:+:,. Well. Foundation <br /> .�; I t. Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED ❑ Di '• Total length/sizesize <br /> Distance to'nearest: Well . Foundation <br /> I Property Line <br /> SEEPAGE PITS I I Depth I Size <br /> SUMPSL7 DiNumber <br /> Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ Property Line <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. <br /> LL r Home owner or licensed agent's signature certifies the following. <br /> employ an g: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> p Y Y person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall em to <br /> tion laws of California." p y persons subject to workman's compensa- <br /> The applicant must call for all required ins ctions. late drawing on rev rse side. <br />' Signed X /� <br /> Title: r _ Dater <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Data rea ` <br /> Pit or Grout Inspection by r f <br /> } Date—.�, F nspection by _ Date <br /> Additional CommentsT <br /> C1 Stk 466 6781 ❑ Lodi 369-3621 ; Manteca 823-7704 <br /> 5-638 <br /> Applicant - Return all copies to Erivironrrental Health Permit/Services 1601 E. Hazelton A3ve P5O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT.DUE: CK <br /> INFO AMOUNT REMITTED. _ ,'CASH fC: <br /> CEIVED BY DATE <br /> PERMIT'NO. <br /> + EH 13.14{REV.1/85) eyfa/ <br /> EH 14-28 •`F!!� <br />