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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE-%ON AVE.,_STOCKTON, CA <br /> "Telephone (209) 466-6781 <br /> PERMIT EXPIRE=S 1 YEAR FROM DATE ISSUED w '' <br /> (Complete_jn Triplicate). 7 work herein <br /> application is <br /> Application is hereby made to the San Joaquin CouQur Ordinance No.District49 for sewage o per-it <br /> No. 1662 for we Ild/or install the pump and the Rules and Regulations of he San Joaquin <br /> made in compliance with San Joaq tY <br /> Local Health District. , ;k- t ' <br /> Cit}T�- Lot Size PM <br /> Job Address <br /> f Phone <br /> Address <br /> Owner's Name Z-1 fl -I If �/ <br /> Phone..? <br /> L F� Address �� __ _ License [�0.-.1. f� W 1 <br /> "Contractor pESTRUGTION ❑ <br /> "TYPE OF WELLIPUMP: NEW WELL Q WELL REPLACEMENT ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ 5EVVDISPOSAL FLO. PROP. LINE <br /> IC LINES _ <br /> DISTANCE TO NEAREST: SEPTIC TANK" AGRICULTURE WELL OTHER WELL. PITSISUMPS <br /> FOUNDATION - -- -' <br /> INTENDED"USE — TYPE-OF WELL '"'PROBL_�E11A AREA^CONSTRUCTION SPECiFIGATIDNS pia. of Well Casing <br /> ❑ Industrial LlOpen Bottom Q Manteca .D-ra. of Well Excavation Specifications r <br /> Type of Casing a <br /> C7 Domesticl Private ❑ Gravel Pack Ll Tracy Depth of Grout Seal Type of Grout <br /> " ❑ Other ❑ Delta <br /> Q Public <br /> ❑ Irrigation __Appeox!Depth-. ❑ Eastern Surface Seal Installed State Work Done t" <br /> 1 Repair Work Dane Q Type of Pump r� H.P- <br /> `Sealing Mateflail (top"501 L - <br /> Well Destruction ❑ Well Diameter <br /> Depth Filler Mate11rial (Below 50'} <br /> j <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ RE A /AD.DlT10N 'DESTRUCTION :availablleseptEw system <br /> 200 feet.) if public sewer as <br /> i <br /> �mmerciaf t Other�� I <br /> i i Installation will serve: Resrce I , <br /> f Number of living units: Number of edrooms m, Water table depth <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments <br /> I <br /> SEPTIC TANK N-,I1pe/Mfg r Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Foundation� Property Line <br /> Distance to nearest: Well <br /> ' LEACHING LINE ❑ No. & Length of"lines <br /> Total length/size <br /> Foundation 3 ._Property Line <br /> + FILTER BED ❑i Distance to nearest: Well <br /> r ❑ Depth Size <br /> Numbers <br /> SEEPAGE PITS <br /> ❑ Distance to nearest:" Well Foundation Property Line <br /> SUMPS rt I <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, and <br /> rules and regulations of the San Joaquin Local Health District.g ' f "" <br /> Hol not <br /> me owner or licensed agent's signature certifies the following: <br /> faevrsoof California."oConitractor s�hirng or sub-const act nglsignlaturre <br /> eZ any person in such manner as to become subject to persons subject to workman's compensa- <br /> cthe following: "I certify that in the performance of the work for which this permit is issued, I shall employ <br /> tiws Califgrnia." <br /> Tplica t st c for all qu" ins ctions om to drawing o verse si �7 <br /> Date: ~] <br /> Title: <br /> Signed <br /> i F DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Pit or Grout Inspection by Date�� <br /> Final Inspection by ° Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 36,9-3621 El Manteca 823-7104 ❑ Tracy 63x6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i CKPERMIT'NO. <br /> FEE RECEIVED BY DATE <br /> AMOUNT DUE AMOUNT CASH <br /> INFO REMITTED <br /> +-EH 13-24(REV.1./ 4�3,S�r - <br /> EH 14-26 - <br />