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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 oto t3 � <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> � (Complete in Triplicate) <br /> all the work <br /> n des <br /> Application is hereby made to the San <br /> C 6a ut Ordinance Health <br /> District <br /> for sewage or cation is <br /> tNo. iBb2 fort to cwellldpump or and the Rules and'R Regulations of tlhe Sais n Joaquin <br /> made in compliance with San JoaquintY + <br /> Local Health District. <br /> d City s Lot Size PM <br /> XJob Address �� 4 ` <br /> t"r� Phone <br /> /Sp.Ci /•/�C' `_� Address <br /> �wnerIs Name LGv� <br /> / �'`Aa License No._— Phone_ <br /> contractor <br /> Address DESTRUGTION� <br /> NEW WELL Q WELL REPLACEMENT ❑ <br /> TYPE OF WELLIPUMP:4 „. w SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ i <br /> SEWER LINES POSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS <br /> FOUNDATION I AGRICULTURE WE } <br /> INTENDED USE TYPE A BLEM ARE ONSTRUCTION SPECIFICATIONS - pia. of Well Casing' <br /> ca Well Excavation <br /> ❑ Industrial ❑ Ope Bottom ❑ Specifications <br /> i� ' ❑ Tracy Type of Casing <br /> ❑ Domestic/Private ❑ Grav Dept of Grout Seal Type of Grout <br /> k -1 Public Ll Other Cl Delta`, _ <br /> I <br /> I 1 Irrigation �._Approx. Depth l 1 Eastern Surface Seal Installed by <br /> . 1 H P State Work Done— <br /> I Repair Work Done Q Type of Pump _—.— <br /> i i` I Sealing Material atop 50'! <br /> Well Destruction ❑ Well Diameter <br /> Depth I Filler Material (Below 561 <br /> o septic <br /> stem P <br /> TYPE OF SEPTIC WORK: N 11 E 11 W INSTALLATION I REPAIR/ADDITION LI DESTRUCTIO availabe wthine200 feet.) if public sewer is <br /> Installation will server Residence Commercial_- Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth o1,3 feet: Capacity.._ -- No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. Q Foundation Property Line <br /> Distance to nearest: Well <br /> f � Total length/size <br /> i LEACHING LINE ❑ No. &:Length of tines Foundation Property Line <br /> FILTER BED ❑ Distance to nearest: Well <br /> � Number <br /> SEEPAGE PITS 11 Depth l Size <br /> SUMPS Ll Distance to nearest: Well <br /> Foundation Property Line <br /> DISPOSAL PONDS <br /> x 1 hereby certify that I have prepared.this application and that the work will be done in accordantie with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> g' <br /> not <br /> Home owner a son in agent's manner as torbecome subjectlto workman's compensa"I certif�that intion lawsoof California." Contractor's thir ngt orr sub-contracting lsignature <br /> employ any p arsons 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 I <br /> tion laws of California." r d <br /> The applicant for II required inspections. Complete drawing on reverse side. <br /> I <br /> Title: <br /> NSigned <br /> F MENT US>t ONLY <br /> Date Area <br /> Application Accepted by <br /> Pit or Grout Inspection by ate <br /> Final Inspection by Date <br /> 1 <br /> Additional Comments: <br /> ❑ Stk 4fi6 6781 ❑ Lodi 3621 ❑ Manteca 823 7104 ❑ Tracy 835 Ei385 �4 <br /> r Applicant • Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., GA 95261 <br /> I <br /> CK <br /> r RECEIVED BY DATE PERMIT N0. <br /> FEE AMOUNT'UE AMOUNT REMITTED �j 1 �} <br /> INFO -3 0 l{ � '� <br /> ' <br /> �� � -1 <br /> 4 ♦ <br /> EH 13-24(REV.t/s 51 <br /> EH 14-29 <br /> E <br />