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APPLICATION.FOR PERMIT � °��w • <br /> i SAN JOAQUIN,LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE;_-TON AVE., STOCKTON, CA <br /> "Telephone f209) 466.6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereb {CO_m_ plete in Triplicate) wtr f y <br /> y made to the San Jo p �• 'e - �- <br /> r a <br /> made in alth Di nce with San Joaquin County Ordinance No.549 for sistrict oewage or No. 1862 for civei plump and a Rules and Regwork herein ulations of the SanrJoaquin <br /> Local Health District. <br /> Job Address,_ <br /> City _,Lot Size."`" <br /> Owner's Name _{ ,t <br /> —.Address <br /> "//"` <br /> Cnntracta/gl:,-zPhone <br /> t !� <br /> Address��[ t/ s3� <br /> P; <br /> TYPE OF WELL/PUMNEW WELL ❑ License No. <br /> WELL REPLACEMENT f-, Ph <br /> ❑ <br /> Phone <br /> PULP INSTALLATION D <br /> DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ OTHER ❑ <br /> ----- <br /> SEWER LINES. DISPOSAL FLD.__—_ PROP_ LINE <br /> E FOUNDATION __ AGRICULTURE WELL` 4 <br /> INTENDED USE OTHER WELL PITS/SLIMPS _ <br /> TYPE OF WELL PR08LEM AREA CONSTRIJCTiON SPECIFICATIONS <br /> 71 Industrial , Open Bottom ` r i <br /> f G Manteca Dia. of Weil Excavation—.__i <br /> D Domestic/Private L1 Gravel Pack ❑ TracyDia. of Well Casing _ <br /> j ❑ Public ❑ Other J ype of Casing_ Specifications <br /> I D Irrigation _ efta PePth of Grout Sea! — Type of Grout <br /> Repair Work Done APDrox. Depth -❑ Eastern Surface Seal Installed by_ �. <br /> 0 Type of Pump � H•P. _ <br /> Weil Destruction ;� State Work Done <br /> Well Di <br /> ameter _ Sealing Material (top 50.1 <br /> r <br /> Depth Filler Material(Belo 50') k _---i— <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION M, REPAIR/ADDITION DESTRUCTION G (No septic$ <br /> t � r <br /> .� ION 1-i P Warn permitted if public sewer is <br /> Installation will serve: Residence_ available within 200 feet.) <br /> Commercial Other <br /> Number of Irving units: Number of bedrooms 1 <br /> Character of soil to a dept of 3 feet: <br /> } SEPTIC TANK 'Ype/Mf r Water table depth i <br /> PKG. TREATMENT PLT. m � � No. Compartments <br /> F �y� Method of D- I <br /> Distance to nearest: Well br Foundation _( —,r~L! <br /> Property Line d <br /> t LEACHING LINE ❑`No. 9 Length of lines 6n <br /> ,i ►. <br /> FILTER BEDTotal length/size—__ <br /> C Distance to nearest:. .•W url8ati - <br /> -- 'Property Line— <br /> SEEPAGE PITS G Depth !S• 1 <br /> SUMPS Di .— Number <br /> ❑ stance to nearest: ell FdUndation <br /> DISPOSAL PONDS 11 Property Line_.. <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 /> Home owner or licensed agent's signature certifies the following: I certify <br /> employ an r •. that in the performance of the work for which this permit is issued, i shall not <br /> y person g such manner into become subject to workman's compensation laws of Cel'rfomia."Contractors hiring«sub-contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The appli�mustll faa4ruireddZinc�tions- Complete drawing on reverse side. I <br /> g /I <br /> Si ned Title:_ Date: <br /> FO DEPARTMENT USE ONLY Q( r <br /> Application Accepted by Date <br /> Pit or Grout Inspection by _ Date— _— Final Inspection b , <br /> .. y <br /> Additional Comments:, ' ` • r <br /> ❑ Stk 486-8781 1: Lodi 359-3621 ❑ Manteca 823-7104 n 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 /> FEE AMOUNT DUE AMOUNT REMITTED C # <br /> INFO CASH RECEfVED 8Y fDATE' PERMIT;N0. <br /> EH1324{REy,t/9 5) ' <br /> EH 14.28 <br />