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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA C��r <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED `i £�` <br /> (Complete in Triplicate) <br /> Applicatio <br /> /or install the work herein described. <br /> is <br /> n <br /> l�ance with SanJoaquin the nn Joaquin Local Health District for a County Ordinance No..549 for sewage or permit <br /> No 1862 for construct <br /> and the Rules and Regulations of tlhe Sanapplication <br /> madJoaquin <br /> Local Health District. <br /> Q V9' � dc� City — Lot Size PM <br /> Job Address �r <br /> Owner's Name <br /> GGw� Address ` Phone <br /> �B rflidc '6 >t1t6lo go/ <br /> NoW Phone <br /> Contractor � � C <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> .. <br /> D!$TANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Specifications <br /> ED Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Type of Grout ' <br /> Depth of Grout Seal yP j <br /> f'1 Public F1 Other <br /> Cl Delta P <br /> Y-A�pprox. Depth I 1 Eastern Surface Seal Installed by <br /> I I Irrigation .' <br /> H.P. State Work Done <br /> Repair Work Done ❑ Type.of Pump <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> l Depth Filler Material (Below 501 <br /> -TYPE OF SEPTIC WORK: NEW INSTALLATION l.! REPAIR,ADDITION DESTRUCTION i I (Noavaseptic <br /> Attic systemithin rented if public seweIS <br /> at <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: --I-- Number of bedrooms <br /> Character`of soil to a depth of 3 feet: r _ <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity - No. Compartments <br /> PKG. TREATMENT PLT. ❑ , Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE E1'--No. & Length of lines �Total length/size r- <br /> FILTER BED ; ❑ Distance to nearest: Well # Foundation-__.1�--_-- Property Line <br /> i <br /> Number <br /> SEEPAGE PITS I I Depth Size <br /> r <br /> SUMPS 0 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 Joaquin Local Health District. <br /> —. - 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 /> Home owner-or- such manner as to become'subject to workman's compensation-laws of_California." Contractors hiring or sub-contracting signature <br /> employ any person in s <br /> certifies the following: certify that in the performance of the work for which this permit is issued, I shall employ 06Hsbhs subiect to workman's compensa- <br /> tion laws of California." <br /> The applicant mus call for all-re d inspections. Complete_drawing on reverse side. <br /> Signed <br /> Title: 1G a/1,¢4-C 0 !ate DfC)'`!' Date:. 'J •° <br /> # EPARTMENT USE ONLY Q <br /> Data Y"� Area <br /> Application Accepted by <br /> Pit or Grout Inspection by D <br /> Date Final Inspection b ` Date__�'t rLL <br /> i <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 /> .Wf FEECK RECEIVED By DATE PERMIT'NO. <br /> INFO MOUNT DUE �AM�OUNT REMITTED SH <br /> EH 13-24 EH 14-26 IREV.i/n 51 V f/L�.. `/1/� •I �� <br />