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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT t' <br /> 1601 E. HAZE.TON AVE., STOCKTON, CA s. Q <br /> Telephone 1;2091 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> i <br /> r: <br /> for sewage or No. 18&2 for weNlpump and the flutes and Regulations of the San Joaquin <br /> Application is hereby made to the San Joaquin Local Healttl.D4sgtrict for agpermit to construct and/or install the work herein described.This application is f <br /> made in compliance with San Joaquin County Ordinance N <br /> Local Health District. <br /> C� � �� City <br /> Besot Size PM <br /> Job Address 1.4 �c Phone <br /> tL 1 Address . / N <br /> Owner's Name <br /> License No,�Phone <br /> -..� Address <br /> Contractor WELL REPLACEMENT. ❑ DESTRUCTION LJ <br /> OF <br /> TYPE WI=LL/PUMP: NEW WELL ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> SEWER LINES �.1 DISPOSAL FLD. PROP- <br /> DIS TO NEAREST: SEPTIC TANK ��— OTHER WELL 1 SISUMPS <br /> FOUNDATION _��--- AGRICULTURE WELL <br /> rLL PROBLEM AREA CONSTRUCTION SPECIFICAT Dia. of Well Casing <br /> INTENDED USE TYP —a� pia. of Well Excav <br /> Bottom nteca <br /> ❑ Industrial ❑ Open sing Specifications <br /> ❑ Domestic/Private L1 Gravel Pack n Delt Depth o e Seat �` 9 <br /> n Other —V <br /> f"1 Public Surtace Seal Installed <br /> I } Eastern �y <br /> I i Irrigation — H P. State Work Done <br /> V <br /> Repair Wor one ❑ Type of Pump l pp <br /> e Weil Diameter Sealing Material (top 50'1 v" <br /> i Well Destruction ❑ <br /> f Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i] REPAIR/ADDITION i l DESTRUCTION availableNo rwthin 200 feet.)c sysfern ited iF public sewer is <br /> Installation will sere: Residence t Commercial f Other <br /> Number of living units: Number of bedrooms Water table depth <br /> kCharacter of soil to a depth of 3 feet: Capacity ' No. Compartments <br /> J� <br /> SEPTIC TANK Type/Mfg Method of Disposal <br /> f PKG. TREATMENT PLT. ❑._ .. Foundation Property Line <br /> I Distance to nearest' Well <br /> Total Iength l size <br /> j LEACHING LINE ❑ No. & Length of lines Property Line <br /> s <br /> FILTER BED L1Distance to nearest: Well Foundation <br /> [` Size Number ;ra <br /> ' SEEPAGE PITS II Depth Proa Line <br /> SUMPS <br /> Cl Distance to nearest: Well Foundation p ' <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an <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, V signature <br /> she not <br /> nsation <br /> s of California. <br /> employ aha fpersonnn:$,I certify that n the pertorema Ice of to <br /> wok for which this permit is issued,I shall emploConty persons rsubj sring ubject to workman's compensa- <br /> certifies g <br /> tion laws of California." <br /> The applicant m all for.all reg1'a in pections. Complete drawing on reverse side. <br /> Title: Date: <br /> Signed X <br /> l FOR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted <br /> Final Inspection b Date <br /> Pit or Grout Inspecti .Date / <br /> f <br /> Additional Comments: <br /> r <br /> ❑ 5tk 466 6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835- 5 <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> IRECEIVED BY DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED SH <br /> INFO <br /> ' ♦ EH 13-24 rpEV.1/K sl � <br /> EH 14-26 <br />