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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone 1209? 466-6781 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> h District for a to /orinstall the work <br /> is <br /> cation <br /> Application is hereby made to the San Joaquin Localcal He No.549 for sewage or permit 1862 for cwellaherein <br /> ealt purnp and the Rules and R gulations of the San+Joaquin <br /> made in compliance with San Joaquin County <br /> Loc` City al Health District. `/J <br /> Lot Size _ �j Jf ,�� PM <br /> �. <br /> Job Address - <br /> �© 1�tofr Yl Address Phone { <br /> Owner's Name _� <br /> Se /3 o Y �Phone <br /> Address License No. <br /> C ntractar DESTRUCTION ❑ <br /> NEW WELL d WELL REPLACEMENT <br /> YPE OF WELL/PUMP: SYSTEM REPAIR ❑ <br /> PUMP INSTALLATION ❑ FLD. - PROP. LINE <br /> �� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES AGRICULTURE W OTHER WELL PITS/SUMPS <br /> FOUNDATION <br /> TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS S <br /> INTENDED USE Dia. of Well Casing \\Il <br /> ❑ Industrial C7 Open Bottom nteca Dia. of Well Excavation <br /> + Type of Casing Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy yp Type of Grout <br />` ❑ Ot C1 Delta Depth of Grout Seal <br /> i i Public Surface Seal Installed by <br /> I i Irrigation ._-.Approx. Depth l 1 Eastern <br /> State Work Done _ <br /> Repair Work D ❑ Type of Pump H P <br /> ruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material l el w 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t7 REPAIR/ADDITION DESTRUCTIO 4No septic system permitted if public sewer is <br /> f available within 200 feet.) <br /> r <br /> Installation will serve: Residence# Commercial Other <br /> Number of of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments <br /> + SEPTIC TANK ❑ Type/Mfg <br /> F Method of Disposal <br /> i PKG.' TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well Foundation P y <br /> f Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Property Line <br /> FILTER BED <br /> © Distance to nearest: Well Foundation <br /> t <br /> i <br /> } } Depth} Size l / Number SEEPAGE PITS Well foundation_ Q Property Line <br /> SUMPS Ll Distance to nearest: <br /> c DISPOSAL PONDS ❑ <br /> I ify that f have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> hereby cert <br /> E rules and regulations of the San Joaquin Local Health District. <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 signature <br /> she not <br /> I employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hirior sub <br /> ng <br /> to workman-contractlscampensa- <br /> certiiies the following: "1 certify that in he performance of the work for which this permitis issued, I shall employ p 1 <br /> tion laws of Calif <br /> The applica must Gemplate on reverse side. ' <br /> Title: Date: <br /> Signed <br /> R Q L-X �(O <br /> —L <br /> Date �• Area <br /> Application Accepted by / <br /> . � a Date <br /> Date Final Inspection by -7 `f <br /> f <br /> Pit or Grout Inspection by r �� Z <br /> f � { <br /> Additional Comments: <br /> ❑ Sti 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Sox 2009, Stk., CA 95201 �j � / <br /> CK~ RECEIVED BY DATE PERMIT'NO. <br /> FEE MOUNT DUE a AMOUNT REMITTED GASH <br /> 1NF0 V- /r—� TU <br /> r.EH 13-24(Rev.;/H 5) 0-0-0 � -0o V� 11 <br /> EH 14-26 - - - <br />