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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL I ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> _ (Complete in Triplicate) <br /> all the work herein described. TWs <br /> cation is <br /> madle inrcoms lance with SanoJoaqu the n County ordinan Joaquin lncie No.649 for sewage ealth District for a or rNo.1862 for t to cwall/dpump atnd the Rules and Regulations of the San l Joaquin <br /> P <br /> Local Health District. 4.,:. <br /> J s- 1�� Cit Lot Size PM <br /> Job Address <br /> 13 4 7J ,� <br /> ` � Address Phone <br /> Owner'.s Name -- -,- <br /> or <br /> v ddress F Dx�c{ 'A License No. 3 Z Phone <br /> Contract <br /> TYPE OF WELL/PUMP; NEW WELL_CI _- r. WELL REPLACEMENT El DESTRUCTION <br /> PUMP INSTALLATION ❑ {""" SYSTEM REPAIR ❑ THER ❑ <br /> DISTANCE TO-NEAREST: SEPTIC TANK SEWER LINES .——DISPOS L FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER:WELL PITS/SUMPS <br /> INTENDED USE` TYPE OF WELL"^•"PROBLEM AREA �CQNS RUCTION SPECIFICATIONS <br /> ❑ Industrial ; -❑ Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Ma <br /> ❑ Domestic/Private ❑ Gravel Pack ElTracy Type of'Casing Specifications <br /> - Type of Grout — <br /> s <br /> 1'1 Public n Other Cl Delta Depth of Grout Seal <br /> 4 � <br /> -I I Irrigation Ap o Depths- 1 I Eastern Surface Seal Installed by - <br /> Repair Work Dane ❑ e of Pump <br /> - H P. State Work Done <br /> Well Destruction Well Diameter '. Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TY- OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I DESTRUCTION I I (Noavailable <br /> septic system permitted it public sewer is <br /> . ,i.,,y,_,._,.,-•„'...,rt_�. � - available within 200 feet.) <br /> Installation will serve:: Residence Commercial--- Other <br /> Number of living units: �� Number of bedrooms '7� / <br /> Character of soil to a depth of 3 feet: S - Water table depth <br /> SEPTIC TANW ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ ". Method of Disposal a. <br /> i .. <br /> (Distance to nearest: Wel! Foundation Property Line <br /> LEACHING LINE ❑ -No. 8-Length of lines Total length/size <br /> f <br /> -FILTER BED' ❑ Distance to nearest: Wel! `° Foundation Property Line <br /> , <br /> s 5' *� / 1� 1 Number <br /> SEEPAGE PITS I 1 Depth Size <br /> SUMPS L�Distancetonearest: Well iDo � Foundation W1 Property line 5 � <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 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, I shalt 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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant t call for all re ired inspections. C_omplete-drawing.on_reverse-side., <br /> Signed X Title: Date: <br /> } FOR DEPAR MENT USE ONLY 1 <br /> * Application Accepted by Date +" Area <br /> .Ri— Date's'" 1 Final Inspection by Oat r- <br /> r Inspection by fi <br /> Addr ro al ommenfs: <br /> ❑ Stk 466-6781 u ❑ Lodi 369-3621 ❑ Manteca -M-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ; <br /> L <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> +•EN 1 .24(REV.5/R 5) ,a,�•1 <br /> EH 14-28 <br />