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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 TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> construct <br /> ribed.This application is <br /> mads n rcamphance with Sano the Joaquin County Ordinance NHealth <br /> o.549 for sfor <br /> ewage or permit <br /> No. 862 for wellldpumPinstall <br /> and the Rules and Regulations of he San Joaquin <br /> Local Health District. 1 l <br /> �j r !�"(72 <br /> rPM <br /> 2 City � Lot Sizer 1 <br /> Job Address Phone <br /> Owner's Name Address �/J l�sC37 P <br /> Address License No. <br /> Contractor DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ID <br /> A <br /> PUMP INSTALLTION <br /> SYSTEM AIR ❑ OTHER ❑ <br /> .DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> PITS/SUMPS <br /> (FOUNDATION GRICUL E WELL OTHER WELL <br /> TYPE OF WELL PROBLE EA CONSTRUCTION SPECIFICATIONS <br /> lNTENDED.USE Dia. of-W.ell Casing <br /> LJ ttom ❑ M Oia.of Well Excavation <br /> ❑Industrial P BoSpecification <br /> ❑ 0o estic/Private ❑ Gravel Pack racy Type of Casing <br /> Type of Grout <br /> Public Ci Other 17. Delta Depth of Grout Seal -� <br /> I Irrigation —.Approx. D th 1 I Eastern H P /SLurfaace Seal installed by - <br /> �1 State Work Done <br /> Repair Work Done ❑ Type of ;� <br /> Well Destruction ❑ Well Dia ere-, Sea1i IF Material(((513.50') <br /> Depth `+ F 11 1'!1 11411aterial (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION MI `:REPAIR/AD IT10N f 1(DESTRUCTION 1 1 lNo septic system permitted if public sewer is a <br /> !! available within 200 feet.) y1 ; <br /> Installation will serve: Residence CommercialOther !y <br /> r Number of living units: f Number of-bediooms_ - <br /> i > N r` Water table depth <br /> Character of soil to a depth of 3 feet:i' No.Compartments <br /> rCapacity <br /> SEPTIC TANK ❑ Type/Mfg• Method Of,isspp <br /> PKG.TREATMENT.,PLT.❑ �r <br /> Distance to nearest: Well Foundation Property Line ` V <br /> f � l <br /> i LEACHING LINE .;•.❑ No.&L4h of fines' T tat ength/size <br /> i �' Foundation �d Property Line <br /> FILTER BED ❑_ Distance to nearest: W8A � <br /> SEEPAGE PITS -1! Deptfi. Size er <br /> SUMPS.;'` r s <br /> '0 Distancce to nearest: Well N d b�P Foundation Property Line <br /> E DISPOSAL PONDS Ordance with San Joaquin county ordinances, slate laws, <br /> t I hereby certify that i have prepared this application and that the work will be done in accoand C <br /> I Hiles and regulations of the San Jiyaqun Lacai Health D3uict. <br /> k "I certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or Iicensisd•agsnt's signature certifies the following: <br /> iE employ any person in such manner as to become subject to workmen's compensation laws of California."Contractor's hiring or sub contracting signature <br /> -. <br /> f certifies the following:."[certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa;. <br /> I_ tion laws of California:" <br /> The applica mugj Call for required i pections. Complete drawing on reverse side. <br /> t Title: Dale: J <br /> k Signed t ^' <br /> i } <br /> DEPARTMENT USE ONLY y� t <br /> Date O Area r <br /> Application Accepted by <br /> i• � Date G <br /> Final Inspection by <br /> Pit or Grout Inspection by; <br /> a Date <br /> J specs ; f <br /> Additional Comments: f f � <br /> (. <br /> C3 Silk 466-6781 0,Lodi 369.3621 ❑ Manteca 823-7104 ❑Tracy 835 6385 Stk.,CA 95201 I <br /> Applicant;Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, { <br /> CK <br /> ffEME[ZUNT REMITTED CASH RECEIVED @Y DATE PERMIT NO. <br /> f iEH tS211NEV.riaSiCtb <br /> 1 EH 1140 <br />