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r {rT APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE I ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) application is <br /> Application is hereby made to the San Joaquin 0 Local <br /> calne Health District for a 549 for sewage mit 1or 1862construe <br /> ellldpump install <br /> nd the Rules and herein <br /> Regulations of This <br /> San Joaquin <br /> made in compliance with San Joaquin County <br /> Local Health District. ® QQ PM <br /> City v ,G'Y� Lot Size <br /> 10 <br /> Job Address <br /> f Phone <br /> ° Address <br /> Owner's Name <br /> License No.�phone_ <br /> � f Address <br /> E Contract WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL E OTHER ❑ <br /> PUMP INSTALLATION CI SYSTEM REPAi DISPOSAL FLD.SEWER LINES PROP_ LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK ��-- OTHER WELL PITSISUMPS <br /> i FOUNDATION AGRICULTURE L <br /> INTENDED USE TYPE OF WELL PROBLEM ARE CONSTRUCTION 5PEClFICATIONS Dia. of Well Casing <br /> ❑ Open Bottom ❑ Mante Dia. of Well Excavation W <br /> ❑ industrial Specifications t <br /> ❑ cy Type of Casing <br /> � Domestic/Private ❑ Gravel Pack Type of Grout q <br /> n Other ❑ Delta Depth of Grout Seal <br /> I'I Public Surface Seal installed by <br /> I I Irrigation —Approx epth l I Eastern H.P. State Work Done <br /> Repair Work Done LJType a ump <br /> rDiameter Sealing Material (tap 50'1 <br /> Well Destruction ❑ <br /> Filler Material lBeiow.50'.j <br /> Depth , available within 200 feetS <br /> .) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I�h,REPAIRIADDITION t DEST.R CTTION l 1 (No septic system permitted if public sewer is <br /> ial.. <br /> Other <br /> Installation will serve: Residence Commerc <br /> — <br /> Number of living units: Number of bedrooms _�; r Water table depth 7m <br /> ,. <br /> Character of soil to a depth of 3 feet: . , F Capacity '� �No. Compartments <br /> SEPTIC TANK ElTypelMfg Method of Disposal ` <br /> I PKG. TREATMENT PLT. D Property Line <br /> Distance to nearest: Well—t— foundation <br /> No. & Len th of lines OL <br /> Total length/size L IOLEACHING LINE g FILTER HED (Dk Distance tonearest: Weil j <br /> �ndtio`n—J—1 _— Property Line <br /> 0. /� so Numbe <br /> Lj� Distance to nearest: r 2. <br /> SEEPAGE PITS I I Depth _, a I—Size Well���—. — S <br /> SUMPS Foundation !/� Property Line <br /> � <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 /> e following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies th <br /> employ any person in such manner as to become subject to workman's compensation taws of California." ploy corsubj cit to workman's tcompensa- <br /> 1 certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons <br /> tion laws of California." <br /> The applicant mus call for all required inspections. Complete drawing on reverse side. / <br /> Signed X <br /> ■ Title: / Date: /� —�t`l <br /> FOR DEPARTMENT USE ONLY # <br /> Date ` Area <br /> Appli tion Accepted by <br /> r rout impaction by <br /> ate �FinalInspection by Date <br /> Additional Comments: <br /> I ❑ Stk 466-6781 ❑ Lodi 369-3 1 ❑ Ma ca 823-7104 El 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 /> FEECK RECEIVED BY .. DATE "ERM 'NOI— <br /> ITTEDINFO ..-AMOUNT_DUE„ AMOUNT REMCASHEH 13-24(REV.i/>i51 eVo G -7_ �'� <br /> EH 14-25 <br />