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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> HAZELTON AVE., STOCKTON, CA <br /> _ Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> permitDistrict for a n <br /> . This <br /> is <br /> cation <br /> Application is hereby made to the San Joan LocalHealth <br /> No.549 or sewage of No. t$62 fforwelitdlinstall <br /> pumpand the Rules and Regulations of hs SansJoaquin <br /> made in compliance with San Joaquin County <br /> Local Health District. <br /> �7f 7z City, J� s� Lot Size PM <br /> Job Address __.!-----. f <br /> Jjrr�S Address Phone <br /> Owner's Name �,,,,«..........,...«...• <br /> ,�•- ---�w`-'e'e" +.""_. <br /> G ! Address License No Phone <br /> Contractor WELL REPLACEMENT DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL O OTHER ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ <br /> SEWER LINES,,---- DISPOSAL FLO. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE'WELL OTHER WELL PITS/SUMPS <br /> - FOUNDATION <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation + <br /> Type of Casing Specifications 1 <br /> ❑ Domestic/Private ❑ Gravel Pack ❑Tracy ;Depth of Grout Sea! Type of Grout - t\ <br /> ❑ Public Cl Other ❑ Delta <br /> 1 Irrigation _.Approx. Depth I I Eastem� Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump <br /> P State Work Done_ <br /> Well Destruction ❑ Well Diameter Seating Materia!(top 501 <br /> Depth Fifier Material(Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIWADDITION l 1 DESTRUCTION t 1 taNaorsepticwthin 200 permitted i! public sewer is r` <br /> i 4ble h�V <br /> _ Installation will serve: Residence Z Commercial^ Other-! ' S <br /> r <br /> Number of living units: L Number of bedrooms <br /> table depth <br /> character of soil ta_a depth of 3 feet: <br /> opacity No. Compartments <br /> r C • <br /> SEPTIC TANK � 0"'TypelMfg <br /> ethod t <br /> PKG. TREATMENT PLT.❑ Mof Disposal <br /> - _�1� <br /> - ) Distance to nearest: Well`�s _— Foundation Property Lue <br /> No. & Length of lines ---. Total length/size <br /> LEACHING LINE 1�( 0 * <br /> FILTER BED ❑ Distance to nearest: Welij�UO3 4, Foundation - Property Line 17 <br /> r <br /> SE�PAGE R►TS I Depth Size R' Number <br /> F <br /> SUMPS UI Distance to nearest: Weil ` Foundation Property Line <br /> DISPOSAL PONDS ❑ `1 <br /> 1 hireby 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 /> Horne owner or licensed agent's signature certifies the followirig:-'-'l certify that in the performance of the work for which this permit is issued, 1 shat!not <br /> empty any person in such manner as to become subject to wiorkman'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,!she!!employ Puns subject to workman's compensa <br /> + t <br /> tion laws of California." i <br /> + Complete drawl on reverse side. <br /> 16 <br /> , The applicant call for;aS1� ui� inspec' n9 <br /> Signed X Title: <br /> tf4k Q&ARTMENT USE ONLY <br /> { /3 <br /> ! Application Accepted by Date Area _�y <br /> I <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: <br /> ❑ SIR 466-5781 ❑ Lodi 369-3621 ❑ Manteca 823-7144 ❑Tracy 835-6305 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazetton Ave., P.O.Box 2009,.Stk., CA 95201 <br /> I � + <br /> FEE AMOUNT DUEAMOUNT REMITTED c SH..-- .� RECEIVED,SY DATE PERMIT NO. <br /> INFO- <br /> .•EM 13.24 tREV.riNsr <br /> @. EH 14-28 <br />