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at- <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 I <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED } <br /> (Complete in Triplicate) <br /> ..,� cation is <br /> - - <br /> ealth <br />' Apphcation'is Vance with to the San <br /> County Ordinance Joaquin Local H No.District49 for sewage or'No.1862 for well/pump and the Rules and IRegulations of he San'Joaquin <br /> made in comp <br /> F Local Health District. +. <br /> , h <br /> Lot Size PM J <br /> Job Address i <br /> Address Phone <br /> ' Owfiers-Narne <br /> 3 w q <br /> Phone <br /> Contractor's Name L License No. DESTRUCTION 0 <br /> TYPE.0i WELLIPUMP:': NEW WELL ❑ WELL REPLACEMENT ❑ <br /> PUMP�INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> ' SEWER LINES- DISPOSAL FLO. PROP. LINE <br /> I h DISTANCE TO NEAREST: SEPTIC TANK -.7_. <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS +� <br /> Dia. of Well Casing <br /> 11 Industrial 4 ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Specifications <br /> ` ❑ Trac Type of Casing <br /> ❑ Domestic/Private ❑ Gravel Pack Deka Depth of Grout Seal Type of Grout <br /> ❑Other <br /> ' ❑ Public R ? - <br /> ? <br /> ---Approx. Depth <br /> ❑ Irrigation ❑ Eastern=—�- Surface-Seal Installed by; <br /> �• State'Work Done <br /> ElH.P. <br /> Repair Work Done Type of Pump <br /> �ISealing Material (top 501 <br /> Weil Destruction ❑ Well Diameter ; <br /> 1 Depth l . �•-- {-Filler_M'aterial (Below-504 ( : _. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION (moi rAIRlADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ` <br /> ` available within 200.feet.) 1� <br /> 'Z, a - <br /> t �� i ' <br /> Installation will serve:ResidenceCammercial Other_�-- s <br /> (' i <br /> Number of living units` Number of edQrooms Water table depth r� <br /> 1 Character of soil to a depth of 3—feet: i� Capacity No. Compartments + <br /> SEPTIC TANK ❑ TypelMfg t I <br /> ii Method of Disposal. <br /> i PKG. TREATMENT PLT. ❑ Property Line <br /> } <br /> Foundation -- .C.LL <br /> Z+ Distance-to.nearest: Well 1. <br /> Total-length/size <br /> 1. LEACHING.LINE� _r t ge No. &Length of lines Y Property Line " <br /> FILTER BED <br /> ❑ Distance to nearest: Well Foundation <br /> Size Number ' <br /> SEEPAGE PITS M.-O'~epth Property Line <br /> SUMPS El Distance to nearest: Well Foundation P Y <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. 1 <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 shall not <br /> s of <br /> ring or <br /> ng <br /> ignature <br /> 4 employ any the person in such rt fY Lha as n the become <br /> orn subject the work workman's <br /> ch this permitis issued,California."l hall employ persons�subject to wcorkman''s compensa- <br /> g:' <br /> 11 tion l of California." <br /> The applica st call �tjo late drawin reversestd <br /> Date: U <br /> Thl s <br /> Signe <br /> FOR DEPARTMENT USE ONLY <br /> r : Date "' Area <br /> Application Accepted by 1 t <br /> Date <br /> Date Final Inspection by <br /> Pit r Grout Inspection by <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 /> .CK.H�-.^...--�.-gECEIVED`BY'`. 't :"' DATE�= 4''E�;PE7RMIT`NO.' <br /> w-FEE^ AMOUNT-DUE AMOl1NT'FEMITTED INFO �!� . <br /> + EH 1344(REV.10183S <br /> EH 14-26 <br />