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APPLICATION FOR PERMIT <br /> SAN JOAQUIN:LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL—&ON AVE., STOCKTON, CA <br /> Telephone (2091 466-6781 <br /> i <br /> PER <br /> EXPIRES 1 YEAR FROM DATE ISSUED - y <br /> I ' (Complete in Triplicate) <br /> 4 <br /> nce No.549 for sewage or No. 1862 for welt/pump and the Rules and Regulations of the San Joaquin a <br /> A lication is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This applrc Joaquin 1s <br /> pp <br /> made in compliance with San Joaquin County Or ' <br /> Local Health District.. . , r 2 3 -]33 <br /> D� Lot Size PM <br /> City <br /> Job Address 3 <br /> Address 0 O <br /> Phone.. <br /> Owner's Name ��'`�"�� >7 <br /> No—License <br /> Address �a pESTRUCTION ❑ <br /> Contractor —_-- yyELL REPLACEMENT Ca } <br /> NEW WELL ❑ - OTHER ❑ <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR-0, <br /> } ,w ...•._ .., __,.,PUMP INSTALLATION ❑ F�-� -"" DISPOSAL FLD. PROP. LINE <br /> I SEWER LINES _�--- PITSI5UMP5 <br /> DISTANCE TO NEAREST: SEPTIC TANK �� AGRICULTURE WELL OTHER WELL <br /> FOUNDATION <br /> TYPE O'F' PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> INTENDED USE ❑ Man Dia. of;Well Excavation <br /> ED].Industrial ❑ Open Bottom - R _ specifications <br /> D Gravel Pack ❑ Tracy Type of Casing Type of Grout <br /> ❑ Domestic/Private -^^ ❑ Delta �� {Depth of Grout Seal l <br /> ❑ Public ❑ Other <br /> _—,pprox. Depth ❑ Eastern Surface Seal installed by <br /> tl ❑ Irrigation , State Work Done <br /> Type of Pump K.P. f <br /> Repair Work Done ❑ Sealing Material (top 50') <br /> I Well Destruction ❑ Well Diameter Filler,Material (Below 50'i <br /> Depth ` <br /> I available within 200 feet.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> IV Commercial. Other <br /> installation will serve: Residence�*- <br /> Number of living units: , <br /> ' Number of bedrooms ._ Water table depth <br /> � � <br /> Character of soil to a depth of 3 feet: G. Capacity-- No. Compartments <br /> { lMfg - —� <br /> ❑ Type �--�� Method of Disposal �J <br /> + SEPTIC TANK *� <br /> PKG. TREATMENT PLT. ❑ # 1 r Foundation Property Line <br /> Distance to nearest: Well <br /> Total:length/size <br /> LEACHING LINE ❑ No. &Length of lines •d — Property Line— — <br /> + '- Foundation <br /> FILTER BED ❑ Distance to-nearest: " Well <br /> Size Number <br /> SEEPAGE PITS ElDepth _ Property Line <br /> SUMPS ❑ Distance to nearest: Well <br /> Foundation_�� <br /> DISPOSAL PONDS ❑ t .....-. --- <br /> I ISPOhereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws,and r <br /> rules and regulations of the San Joaquin-Local Health District. performance of the work for which this permit is issued, I shall not <br /> r signature <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the, <br /> employ any person in such manner <br /> er n the come perfoEancecof the work for which pe m ttion is issued,fI shall employ persons <br /> ­I <br /> to workmanis9ompensa <br /> certifies the following:"I certify , -1 <br /> tion laws of California." , " <br /> ' The applicant must call for all required inspections: Complete drawing on reverse side <br /> Date: <br /> " Title: <br /> Signed <br /> FOR DEPARTMENT USE ONLY ���: <br /> ^� Date Area <br /> Application Accepted byDate <br /> d 'Final Inspection by <br /> I Date <br /> Pit or Grout inspection by t <br /> Additional Comments: ❑ Lodi r. -3621 ❑ Manteca 823-7104 ❑Tracy 835,6385 Stk., CA 95201 <br /> ❑ Stk 466-6781 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. B <br /> ' ox <br /> RECEIVED BY DATE PERMIT'NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO ; ���/ Y� <br /> + EH 13-24 IREV.1/0 51 .� • (� Oma'/ _ <br /> EH 1426 <br />