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4 APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT � Fi <br /> V, 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781ti <br /> PERMIT EXPIRES i YEAR FROM DATE ISSUED OCr 1889 <br /> (Complete in Triplicate) f tcTlf"�`I fS <br /> ea �� �� ti� � <br /> hued.This application is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wqr� ereem pi_�y <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welllpump and the Rules aii��'ft� t �Cfjd San Joaquin <br /> Local Health District. <br /> ,� City Lot Size PM — <br /> Job Address <br /> r E 7 3`�$r �_f r� Phone <br /> Owner's Nai — Address <br /> �� r <br /> A <br /> Phone <br /> CoilttaCtOr Address # <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT• 0, DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ <br /> DISPOSAL FLD. PROP. LINE <br />' FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS s �1 <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca <br /> Dia. of Well Excavation ' Dia. of Well Casing 1 <br /> ` Type of Casing Specifications C <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy yp Type of Grout — <br /> n Public 1-1 Other Cl Delta Depth of Grout Seal yp <br /> I Irrigation �..Appraz.'Depth l I Eastern Surface Seal Installed by <br /> State Work Done <br /> Repair Work Done [�D, Type of Pumpl <br /> Well.Destruction ❑�t Well Diameter Sealing Mat to d(top 501 -- <br /> %" <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW WSTALLATION I i REPAIRIAf]DITION I I DESTRUCTION'!wh�availablelwihin 200 feetperm.) if public sewer is <br /> Installation will serve: Residence_Commercial tOther <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil toodepth of 3 feet: <br /> t Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg( t . <br /> Method of Disposal <br /> PKG, TREATMENT PLT CI , � +� k ry <br /> Distance to nearest: Well - Foundation Property Line <br /> LEACHING LINE Ll No. & Ler 9th of lines <br /> 1 Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line — <br /> 1 <br /> SEEPAGE PITS l I Depth Size Number <br /> L1 -oistance to nearest: Well Foundation Property Line <br /> _:--SUMPS--- \ <br /> I <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordan a with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health Di%trict, .. .j y <br /> Home owner or licensed agent's signature certifies the toli6wing: "I certify-that in the performance of the work for which this permit is issued, I shall not <br /> f California."' Contractor's hiring or sub contracting signature <br /> employ any person in such manner as to become subject to workman's compensation laws o <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 /> Theapplicant mu or all requir i pecbons. Complete drawing on reverse side. �^ <br /> Signed X� <br /> Title: Date: o- — /Y <br /> FOR DEPARTMENT USE ONLY 11 } <br /> ' Date 10—a�IlArea <br /> Application Accepted by Pit or Grout InspectionDate Final Inspeetion byDate% <br /> Additional Comments: <br /> l ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-171-04. 0 Tracy 835-6385 <br /> f nmental Health Permit/ E�Hazelton Ave., P.O. Box 2009, Stk., CA 9520 <br /> Applicant- Return all copies to: Enviro1 <br /> FEECK RECEIVED BY DATE PERMIT NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> EH 13-24 MEV, <br /> EH 14-2a <br /> A <br />