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APPLICATION FOR PERMIT <br /> 1 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA, 1 ' <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED I <br /> (Complete in Triplicate) Gcation is <br /> constru <br /> herein describe , This app <br /> Application is heieby made to the San Joaquin <br /> Joaquin County OrdcalnHealth <br /> District <br /> for sewage or for a peINo�1$62 forcwand/or install the Work ell pump and the R l s and Regulations of he S n Joaquin i <br /> made in compliance with <br /> Local Health District. <br /> ) City Lot Size PM <br /> Job Address <br /> x 1r 0 Lc Phone <br /> Owner's Name - Address <br /> � <br /> rPhon <br /> 3�3� License No. <br /> Address"` DESTRUCTION ❑ <br /> Contractor " <br /> WELL REPLACEMENT ❑ r & <br /> TYPE OF WELL/PUMA: NEViI WELL ,Q..,. ` OTHER ❑ <br /> "` { r `zSYSTEM REPAIR.❑ <br /> PUMP INSTALLATION ❑ <br /> rSEWERwLINEB' __�—=-- DtSpOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK � = r OTHER WELL PITS/SUMPSA7, <br /> FOUNDATION AGRICULTURE WELL,INTENOfD USETYPE OF WELL I' PROBLEM AREA= CONSTRUCTION SPECIFICATIONSDia. of Well,Casing <br /> ❑ bpen Bottom ❑ aneDia. of Well Excavation❑ Industrial ,rType of Casing Specification's❑ Gravel Pack ❑ Tracy iType of Grout❑ Domestic/Private Deptfi of Grout Seal <br /> r'-1 Other r'7Delta('1 Public rface 5eal.lnstalledI I lrriyation —.Approx. Depth f Eastern H P State Work DoneRepair Work Done ❑ Type of Pump __.—.- --Well Destruction ❑ Well DiameterSealing Material (top 50'1 <br /> Depth Filler Materia! (Below 50'1 <br /> k _ -,. ,F. -- ". .. "avails within 200 fee I I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION la RI_VAIR/ADDITION t 1 DESTRUCTIO INo septic system permitted,it publics r is \ <br /> rCommercial— Other <br /> Installation will serve: Residence� VV <br /> Number of living units: Number of bedrooms i -Water table depth <br /> Character of soil to a depth of 3 feet: Ca acity`� A .�No.'Compartments <br /> ❑ Type/Mfg p 4 <br /> SEPTIC TANK Method of Disposal <br /> PKC. TREATMENT PLT.❑ iProperty Line r <br /> Distance to nearest: ` Well Foundation�---. <br /> -_ .Total fength1size y <br /> LEACHING LINE ❑ No. &Length of lines inearest: Well Property Line ' t <br /> ❑ Distance to neFoundation <br /> k \ FILTER BED I – t L ..- <br /> FI (� SEEPAGE PITS C I Depth <br /> Property Line <br /> L� Distance to nearest: Well Foundation P rty b5 <br /> SUMPS ,.„ <br /> DISPOSAL PONDS ❑ <br /> ,ti 41 '' 0 1 <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 a ant's signature certifies the following: "I certify that in the performance of the worts for which this permit is issued, I shall not <br /> employ any person in ed manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: emsrtifthat s the performance of the work for which this permit is issued, I shall em rsons subject to workman's compensa- <br /> tion laws of if r - T <br /> 1 all for equir ns. Co a wing on verse si <br /> The applic t 6 <br /> Date: <br /> Title: <br /> f Signed X <br /> FOR DEPARTMENT U ONLY <br /> Date Are <br /> ( <br /> Application Accepted by pate Final Inspection by � Date 3 v <br /> Pit or Grout Inspection by— <br /> y t <br /> Additional Comments: F <br /> I ❑ Stk 466-6781 .❑ Lodi 369-3621 11 Manteca 823-7144 ❑ Tracy 835.6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Sarvices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 <br /> CK RECEIVED BY DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH 9 f f <br /> l <br /> INFO <br /> +,EH 13-24 IREV.t - <br /> EH 14.28 <br />