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APPLICATION FOR PERMIT <br /> SAN <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1`YEAR FROM DATE ISSUED Ll�iV4ltt.,,!t� .},fAL HEALTH <br /> r �EI�VICES <br /> jq-.ln <br /> (Complete in Triplicate) t�.ht�lI/nce No.549 for sewage or No. 111&2 for well/pump and the Rules and Regulations of the San Joaquin <br /> A plication is hereby mads to the San Jd nal Health District for a permit to construct and/or install the work herein described. This application 1s <br /> P <br /> made in compliance with San Joaquin Co linty r <br /> Local Health District. { PM <br /> Cit _ Lot Size <br /> Job Address ln-�� <br /> - Phone <br /> Address � l u <br /> Owner's Name � 7 <br /> License No. Phon <br /> Address <br /> ContractWELL REPLACEMENT ❑ DESTRUGTION LJ <br /> OF WELLIPUMP: NEW WELL ❑ _ EJ OTHER C3SYSTEM REPAIR <br /> PUMP INSTALLATION X '� DISPOSAL FLD. PROP. LINE <br /> SEWER LINES - <br /> --- p{T515UMPS <br /> t DISTANCE TO NEAREST: SEPTIC TANK _�� AGRICULTURE WELL OTHER WELL <br /> FOUNDATION <br /> INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> Open Bottom ❑ Manteca Dia. of well Excavation <br /> ❑ Industrial Specifications <br /> pee <br /> D Tracy Type of Casing <br /> (�.BomesticlPrivate ❑ Gravel Pack � '-Type of Grout = <br /> F 7 Other +.; M Delta Depth of Grout Seal <br /> [I Public y Surface Seal installed by <br /> 1 I I Irrigation —..Approx. Depth i I Eastern �'L� State Work Done <br /> _ H.P. ! <br /> Repair Work Done ❑ Type of Pump Sealing Material (top 501 <br /> Well Destruction ❑ Well Diameter <br /> Depth <br /> Filler Material ISelow 501 torn p <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIRlADDITION 1.1 DESTRUCTION t I (Nailseptiable withSin 200 feet.) if public sewer is <br /> Other <br /> installation will serve: Residence" Commercial.� ' <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: Capacity— <br /> No. Compartments <br /> j SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> ft PKG. TREATMENT PLT. ❑ - Foundation��.Property Line <br /> - Distance to nearest, Well <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Property Line <br /> 5 FILTER BED <br /> ❑ Distance to nearest: Well <br /> Foundation �- <br /> Size Number <br /> k SEEPAGE PITS C I Depth Property Line <br /> [ Ll Distance to nearest: Well Foundation + .� <br /> SUMPS { <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared,this application and that the work will be done in accordarti a with San Joaquin county ordinances, state laws, d <br /> rules and regulations of the San Joaquin Local Health District. <br /> g work for <br /> Home owner or licensed.agent'sagas torbecome sub efolto wing: "I n`s�compensation Iify that in the la soof California."Contractor's�hui gI of sub-cont act sub-contracting <br /> employ any person in such man persons <br /> subject to workman's compensa <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ p 1 <br /> tion laws of California." �- <br /> I The applicant mu all for all req •red inspections. Complete drawing on r arse side. <br /> Title: <br /> I Signed - w4 <br /> , - pp ENT USE ONLY j <br /> -7a <br /> — -S <br /> a <br /> 1 Date - /�- <br /> Application Accepted by Date - <br /> Pit or Grout Inspection by <br /> Date.��-- Final Inspection by <br /> k Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823 7144 I❑ Tracy 835-6385 <br /> Applicant Return all copies to: Environmental HeP.O. Sox 2009. Stk., CA 95201 <br /> Health Permit/Services 1601 E. Hazelton Ave., <br /> GK RECEIVED SY DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CAS <br /> INFO <br /> t EN 13-24 IREV,t i n 51 V L - <br /> EN 1428 <br />