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:4L. <br /> APPLICATION FOR PERMIT <br /> tx. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 i <br /> :. PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> I . (Complete in Triplicate) , <br /> cribe <br /> . This <br /> cation is <br /> Application is hereby made othe Joaquin County SanJoaquin <br /> Ordinalncle No.549 for sewage or INo t to 1862 forcwell/Pomp and the Rules and Regult a / r install the work herein ations of he San appll Joaquin <br /> made in compliance with SanJoa q '.� <br /> Local Health District. <br /> ICite� Lot Size <br /> ss Phone <br /> Job Address r , <br /> ;9i, <br /> - <br /> Owner's Name �j/�� r <br /> Lam- -` <br /> .. ;3 4Phone <br /> Contractor <br /> Address '�!<- License N � <br /> TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT LlDESTRUCTION:❑.. Ht, <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C] `;►,' OTHER ❑ . <br /> * ` 'DISPOSALFLD. PROP. LINE4 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES __--- PITS/SUMPS., _` <br /> FOUNDATION AGRICULTURE WELL i. OTHER WELL <br /> INTENDED USE TYPE OF,WELL PROBLEM AREA' r CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> C] Industrial ❑ Open Bottom ❑ Manteca i Dia. of Well.Excavation Specifications <br />€ ' Type of Casing <br /> fl <br /> Domestic I Private ❑ Gravel Pack © Tracy �� �y _.,� Type of Grout <br /> ❑ Other Ll Delta Depth of Grout Seal. f <br /> M Public I <br /> I Irrigation _.Approx. Depth 1.1 Eastern Surface Seal Installed by ; <br /> tt W.P:! State Work Done"— <br /> Repair Work Done Type of Pump 14, <br /> Well Destruction ❑ Well Diameter r z Sealing.Material Ipop 50'1 <br /> l <br /> Depth t,,.Fiiler Material iBelow 501 M y U <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l ] DESTR ACTION ,1 I available lwi within feet <br /> itled if public sewer is <br /> € Installation will serve: Residence Y Commercial_ Other <br /> Number of living units: —� Number of edrooms 0(> - <br /> Water table depth <br /> Character of soil to a depth of 3 feet: �� No. Compartments <br /> SEPTIC TANK Type/Mfg io Capacity ` <br /> Method of,DispPsal 4c �- <br /> PKG. TREATMENT PLT. ❑ - lb _ Property.Line +�+'`"— <br /> Distance to nearest: Well Foundation <br /> Total length/size- _�x'. <br /> LEACHING LINE No. & Length of lines - �� �� <br /> d FILTER BED ❑ Distance to nearest: Well <br /> /'� Foundation,__/� property Line - <br /> k <br /> —Size <br /> SUMPS <br /> Number <br /> SEEPAGE PITS I I Depth Property Line <br /> SUMPS Cl Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ - <br /> 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 that in the performance of the-work for which this permit is issued, I shall not' <br /> employ any person in such manner as to become subject to workman's-compensationIMAs of Califoriiia_" Contractor's hiring or 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 comPonsa- <br /> tion laws of California-" + <br /> The applicant must call for all taquirio inspections. Complete drawing on raver e side. <br /> Title: Date: <br /> Signed X t <br /> FOR DEPA TMENT USE ONLY <br /> Date ✓ Area <br /> [ Application Accepted by <br /> f pats Final inspection by ' Date <br /> i Pit or Grout Inspection by df <br /> Additional Comments , <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Ma teca 823-7104 ❑ 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 /> FCK RECEIVED BY DATE PERMIT'NO. <br /> EE <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> ..EH 13.24(REV.i/n 5) 1�D <br /> EH 14-28 ' <br /> .: ria.,. <br /> a <br />