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APPLICATION FOR PERMIT <br /> SAN JOAQUIN,OCAL'HEALTH DISTRICT <br /> ELA �, <br /> 1601 E. HAZ' '�T�ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED jQ <br /> r <br /> (Complete in Triplicate) <br /> !� /or install the work ( application is <br /> Application is hereby made to the San Joaquin LHealth District fora ocal <br /> No.549 for sewage or INo t to 1862 forcwelildpump and the Rules and construRegulations of tthe San Joaquin <br /> made in compliance with San Joaquin County ordinance + <br /> Local Health District. / <br /> ' r City Lot Size 100 X /n <br /> J — PM <br /> .fob Address <br /> 7 Phone <br /> � Address _ <br /> Owner's Name f,f S �, ( [� <br /> + j License No./ l!:-'� Phone�r V " Z <br /> Contractor . Address <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑�;. <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION 'I] I <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWE LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGR ULTURE WELL OTHER WELL PITS/SUMPS .� <br /> INTENDED USE TYPE OF WELL PRO LE AREA CONSTRUCTION SPECIFICATIONS Dia..of Well Casing <br /> ❑ Industrial EI Open Bottom ❑ M ca_ .Dia. of Well Excavation <br /> Type of Casing Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tr y` Depth of Grout Seal <br /> Type,of Grout <br /> ❑ Public ❑ Other ❑ D It 4 d <br /> Approx� Depth. I 1 ast n Surface Seal Installed by t <br /> I 1 Irrigation — r r ,_ State Work Done <br /> Repair Work Done ❑ Type of Pump H.P• <br /> Well Destruction ❑ Well Diameter Sealing Material Stop 50'1 1 <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [J REPAIR/ADDITION l i DES U TION (Nailablelwthine2 permitted <br /> g fitted if public sewer is <br /> f I <br /> f 7i <br /> Instaliation will serve: Residence Commercia Othe <br /> - _ <br /> Number of living units: Number of bedroomsw Water table depth <br /> Character of soil to a depth-of.3 feet: No. Compartments <br /> SEPTIC TANK LJType/Mfg Capacity <br /> Method of Disposal <br /> i t ` <br /> PKG. TREATMENT PLT. ❑ ` <br /> t t - Distance to nearest: Well Foundation.a. Property Line <br /> Total length/size <br /> LEACHING LINE 0 No ✓� Length of lines "Property Line <br /> ❑ Distance to nearest: Well Foundation <br /> FILTER BED <br /> I I _ :> i <br /> 1 SEEPAGE PITS � I 1 DepthSize Number,., � . <br /> SUMPS LlDistance to'neare <br /> Weil Foundation <br /> Property Line <br /> # DISPOSAL PONDS ❑ I <br /> I hereby certify that I have prepared this app kation and that the work 11 be done;in accordance with San Joaquin county ordinances,{state laws, an <br /> rules and regulations of the San Joaquin Local Health District. <br /> g: ,. <br /> Hama owner or licensed agent's signature certifies the following: <br /> I certify hat in the performance of the work for which this permit is issued, I she not <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 /> a certifies the following: "I certify that in the performance of the work'for.which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion'laws of California." �; ; <br /> r iicant must call for II required ' spections. Complete drawing on reverse side. t <br /> F The app q 1-.� ' <br /> Title: <br /> Date: <br /> Signed X <br /> r FOR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by <br /> Date Final Inspection by <br /> ' ��J Date <br /> Pit or Grout inspection by ' <br /> Additional Comments: <br /> F ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant Return all capias to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CK RECEIVED BY DATE PERMIT'NO• /'/J� <br /> FEE AMOUNT 6UE AMOUNT REMITTED CASH <br /> INFO <br /> a.EH 53-24(REV.17 H 51 <br /> EH 14-2e <br />