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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> alth District for a construct and/or <br /> is <br /> Application is hereby made to the San Joaquin uca nce No,549 for sewage or Permitto <br /> 1862 for welO PumP install herein <br /> He cation <br /> nd the fl s and R gulations of he San' <br /> Ordina <br /> ereJoaquin <br /> made in compliar ce with San Joaquin County <br /> Local Health Disl�ict. PM ��(f„ <br /> e City Lot Size v� <br /> Job Address <br /> Phone <br /> Address <br /> AL1 <br /> Owner's Name r <br /> �1 �Pcti'�2, <br /> ense No Phone <br /> Contract I� 4koldress L <br /> CWELL REPLACEMENT ❑ DESTRUCTION L1TYPE OF WELL/PUMP: NEW WELL OTHER El INSTALLATION SYSTEM SYSTEM REPAIR ❑ ®(� PROP LINE® B <br /> m Q"r SEWER LINES DISPOSAL FLD. <br /> DISTANCE TOylVEAREST: SEPTIC TANK _ ..� plTS15LIMPS <br /> j� FOUNDATION <br /> �� AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI / pia. of Well Casing 5 <br /> ❑ Ind al en Bottom ❑ Manteca Dia- of Well Excavation Specifications <br /> Type of Casing <br /> omesticlPlivate ❑ Gravel Pack •+ ❑ Tracy of h <br /> bA • TYP <br /> C! Other M Delta.,t». Depth-of Grout Seal <br /> l'l Public i z ti ✓ <br /> I 1 Irrigation --Approx. Depth I i stern �� Surface Seal Installed by �.,. <br /> ,-Repair Work Do one ❑ Type of Pump <br /> _H P -.3 State Work Done <br /> ~ �-� '"`�SeaGrig Materia4'(tdp 50'1 <br /> Well Destruction ❑ Well Diameter _ _ „ w <br /> Deptli Filler Material (Below.50') . <br /> TVPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I i available septic hie 200 leetrt'ed if public sewer is <br /> t Installation (will serve: Residence; Commercial ' <br /> Other <br /> k I <br /> Number of living units: Number of bedrooms Water table depth <br /> i Character of soil to a depth of-3 feet: No. Compartments <br /> ❑ Type/Mfg Capacity \J� <br /> SEPTIC TANK Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Foundation Property Line <br /> Distance to nearest: Well ; r-„ Y <br /> t - , Total length/size <br /> LEACHING LANE ❑ No. & Eeir of fines <br /> �{ FILTER BED: ❑ Distance to nearestt�:m«Well <br /> 4 Foundation Property Line <br /> s. <br /> T a Number <br /> SEEPAGE PITS 11 Depth 't Size <br /> Property Line <br /> 9 " SUMPS If "❑ " Distance to nearest; 4V41ef1^ Foundation <br /> DISPOSAL PONDS ❑ <br /> r I hereby certify that f have prepared this application and that the work will lie done'in' ccord�ance with San Joaquin county ordinances, state laws, and <br /> ealth District. <br /> rules and regulations of the San Joaquin Laval Hwork for <br /> 1 l not <br /> Home owneri or licensed agent's signatorbecome subject to workman's kman srtcompensation lfy that in the aws Californian"Contracctor's�hui gr or sub-contracting signature <br /> employemploy any person in such manner as ersons subject to workman's comperl <br /> ' certifies the following: "I certify that in the performance of the work for which this permit is issued,l shall employ p 1 <br /> .tion laws of:California." <br /> The applicant m call for all requ' inspections. Complete drawing on reverse side. <br /> I Title: '� Date: <br /> Signed X , <br /> FOR DEPARTMENT USE ONLY <br /> Are <br /> Date 0'3 <br /> Application iAccepted by l .� ��-F <br /> M. f! Final Inspection by Dat <br /> Pit or rout) nspection b Date <br /> �dditinnal Comments: c� <br /> Stk 466-6781 Lodi 369-3621 ❑ Manteca 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 85201 <br /> FEEREMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> AMOUNT DUE AMOUNT <br /> INFO CA H X7-3 ys- <br /> + EH 13-241REV.i/H5) <br /> EH t4-2a <br />