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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 i <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> R (Complete in Triplicate) <br /> all the work <br /> made n rs lmade <br /> Sano the Joaqu n County Ordinance i Joaq.urn lNth District for a o. 549 for sewage or It to Na 1862 forcwellldpump atnd the Rules and IR Regulationsofof he San{cation is <br /> Joaquin <br /> made incompliance <br /> Local Health District. <br /> ' 1 � r•PM <br /> City Lot Size <br /> Job Address � ` I <br /> ' - Phone <br /> Address <br /> Owner's Name �( '7V _ <br /> r� Address <br /> ' '� s License No.�ly V_..i f?Phone '�92 <br /> Contracta <br /> �F LL REPLACEMENT D DESTRUCTION TYPE OF WELL/PUMP: NEW WELL' WEEJ <br /> PUMP INSTALr' TION SYSTEM AIR ❑ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES .DISPOSAL FLD. PROP. LINE <br /> FOUNDATION GRICUL EWELL OTHER WELL PITS/SUMPS <br /> TYPE OF WELL PROBLE EA CONSTRUCTION SPECIFICATIONS <br /> tNTENDED.USE Dia. of Well Casing <br /> D Industrial D Open Bottom ❑ M e Dia. of Well Excavation <br /> Type of Casing Specification,--, _ <br /> ❑ 0 estic/Private D Gravel Pack racy yp Type of Grout — <br /> Public LI Other F Delta Depth of Grout Seal <br /> _..Approx. D th I I Eastern Surface Seal installed bye <br /> I I Irrigation H P '*.�_ State Work Done _ <br /> Repair Work Done LJ Type o1 u / -,ti <br /> i Well Destruction ❑ Well Diameter Seali g Material Itap,50') — <br /> Depth I/` Filler aterial IBelow 50'1 <br /> TYPE OF SEPTIC WORK: NEW�INSTALLATIONVI '-�EPAIRIAD ITION I 1 /DESTRUCTION I I aNailabPe'wthin 200 feet.) <br /> iued if public sewer is <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Number of-b? rooms <br /> !�� Water table depth �( <br /> Character of soil to a depth of 3 feet:; V No. Compartments t \�i <br /> r � Capacity . � N <br /> SEPTIC TANK ❑ Type/Mfg Method of Dispos <br /> PKG. TREATMENT,PLT. ❑ <br /> Distance to nearest: Well ry Foundation ,Property Line <br /> f Total length/size ,. <br /> D No. & Length of lines': <br /> .. <br /> i LEACHING LINE . 2.4 Property Line <br /> I FILTER BED , ❑_ <br /> Distance to nearest: Well A� /✓-,� Foundation <br /> f Size - tuber <br /> SEEPAGE PITS I I Depth. 7/f�/r— <br /> h d 1y Foundation Property Line <br /> ' SUMPS. `1 L1 Distance to nearest: Well <br /> t DISPOSALPONDS.P' ❑ <br /> t ! 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 '"b <br /> t Health Dtrict. <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 /> rules and regulations of the San Joaquin Loca <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> f certifies the following: "I certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa; <br /> tion laws of California." {^ <br /> The applica mu�call for. required i pections. Complete drawing on reverse side. ` <br /> + Title: G� i Daie: l <br /> Signed X j ---' <br /> F DEPARTMENT USE ONLY <br /> t <br /> ' Date �— Area t <br /> Application Accepted by 1 - <br /> { 3 Date Final Inspectionby Date ZZ, r <br /> Pit or Grout Inspection by <br /> F r <br /> Additional Comments: # � <br /> l D Stk 466-6781 �. DLodi 369-3621 ❑ Manteca 823-7104 D Tracy 635-6385 <br /> ( Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i <br /> CK <br /> E AMOUNT REMITTED CASCASHRECEkVED BY DATE PERMIT N0. <br /> FEE AMOUNT DU <br /> INFO Ctb <br /> 13-24{REV.1/9 51 <br /> Y EH 14-2e <br />