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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 7601 E. HAZE i ON AVE., STOCKTON, CA f <br /> Telephone {209} 466.6781 <br /> j PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED A <br /> (Complete in,Triplicate) 1 a f <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 <br /> Local Health District. for well/pump and the Rules and Regulations of the San Joaquin <br /> T <br /> Job Address (� X, oa <br /> ti. City Lot Size Vy !(J PM <br /> Owner's Name <br /> AddressPhone <br /> F <br /> Contractor Address ( 5i <br /> TYPE OF WELL/PUMP: gNEW WELL El WELL REPLACEMENT LlPhon, <br /> DESTRUCTION ❑ <br /> PUMP,IINSTAf;L•a4T4GN-Q _._ - _��__SYST•EM-FIEPAIR-p. - - <br /> DISTANCE TO NEAREST: SEPTIC TANK �.._ SEWER LINES OTHER <br /> DISPOSAL F PROP. LINE <br /> FOUNDATION AGRfCULT,U_RE WELL ELL PITS/SUl1AP5 <br /> INTENDED USE :TYPE OF WELL PROBLEM AREA C CTION SPECIE CATIONS <br /> ❑ industrial ❑ Open Bottom ❑ Man Dia. of Well Excavation <br /> ❑ Domestic/Private ❑ Grave! Pack Dia. of Casing <br /> 0 Gr Tracy Type of Casing <br /> ❑ Public Specifications <br /> x ❑ Delta Depth of Grout Seal <br /> ❑ Irrigation ,q 'Type'of Grout <br /> 1---Approx. Depth ❑ Eastern usface 5eal.lnsta[!ed by r <br /> Repair Wor e ❑ Type of Pump H.P. State Work Done 1 t <br /> Weil estruction ❑ Well Diameter r <br /> Sealing Material (top 50') <br /> Depth ; <br /> p Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/AD DITIO�d�❑� p RUCTION o septic system permitted:if public sewer is <br /> Installation will serve: R idence_ I Commercial` Other U vailabl Within ,) <br /> �4 <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: ? I <br /> SEPTIC TANKWa <br /> Type/Mfg ter table depth 11 <br /> I Capacity_ No. Compments <br /> art <br /> PKC. TREATMENT PLT. ❑• #rvj. 1 � <br /> 3 Method,rof Disposal <br /> Distance tbnearest: Well Foundation Property Line _r <br /> a <br /> LEACHING LINE ❑l No. & Length of lines <br /> t Total length/size ¢ "y <br /> FILTER BED t ❑€ Distance to nearest: well�_ Foundation Property Lime <br /> 1f <br /> SEEPAGE(PIT ❑i. Depth Size <br /> Number <br /> SUMPS -CJ Distance to-nearest: Well Foundation <br /> ,DISPOSAL PDNDS 4--. ❑f "Property Line�^��'" <br /> (I Feieby certi# 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 iSan Joaquin Local Health District. <br /> Home owner or:licensed agent's signature certifies the following: <br /> y performance of the c for which this permit is issued, I shall not <br /> employ an, r g: "I certify that in the <br /> p y yt rson in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the(Allowing:"I certify that in the performance of the work for which this permit is,issued, I shall em Io r <br /> tion laws of California." ! f .-� _ t Y�persons subject to workman's compensa- <br /> tion <br /> applicant ust call for required nspections. Complete drawing on reverse side. <br /> Signed XTitle: r 5�1r4 l <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted <br /> Date Area <br /> Pit or Grout Inspec ' Date Final Inspection by �wwr �-- �,�l <br /> _ Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-710 ❑ Trac 835-6385 f <br /> Applicant- Return all copies to: Environmental Health Permit/Service'160 E)Hazelton Ave., P.O. Box 2009, Stk., GA 95201 <br /> i <br /> FEE AMOUNT DUE AMOUNT REMITTED GK <br /> INFO zc CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24(REV,r/w 5) <br /> EH 14-ZB s <br />