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r y v <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466.6781 1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED v <br />> (Complete in Triplicate) <br />{+ Application is hereby made to the San Joaquin Local Health District fora ' <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage No. 1862 for pump andtall the Rules and Regulations the San Joaquin <br /> Local Health District. ins erein thework application <br /> f <br /> Job Address <br /> City Lot Size <br /> Owner's Name PM r }f" r <br /> A ress <br /> Phone <br /> Contractor <br /> ddress <br /> AV <br /> TYPE OF WELL/P MP: NEW ELL ❑ License No. Phone <br /> PUMP INSTALLATION El WELL REPLACEME T ❑ DESTRUCTI0 ' <br /> DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ OT ER <br /> S LINES DISPOSAL FLD. <br /> FOUNDATION AGRICUL RE W PROP. LINE <br /> INTENDED USE OTHER WELL PITS/SUMPS <br /> TYPE OF WELL PROBLEM AR FRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Mant y <br /> ❑ <br /> Domestic/Private Dia. of f Excavation <br /> ❑ Gravel Pack Dia. of Wel! Casing <br /> ❑ Public racy Type of Casing <br /> ❑ Other ❑ DeltaSpecifications <br /> EJ Irrigation Depth of Grout Sea <br /> —A` x• Depth ❑ EasternType of Grout <br /> Repair Work Done ED Type of Pump H.P. Surface Seal Installed b <br /> - ate W6 Done <br /> Depth <br /> Weil Destruction El Depth <br /> Diameter <br /> St <br /> Sealing Material {top 50') <br /> F* <br /> TYPE OF SEPTIC WORFiller Material (Below 50') <br /> K: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO <br /> r {No'septic system permitted if public sewer is <br /> Installation will serve: Residence_ Commercial— available within 200 t.)feeOther V <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: § <br /> SEPTIC TANK ❑ Type/Mfg Water table depth <br /> PKG. TREATMENT PLT. 71Capacity��- No. Compartments <br /> Distance to nearest: Well """^ Method of Disposal <br /> r Foundatidn Property Line "^` <br /> LEACHING LINE ❑ No. & Length of lines <br /> FiLTER BED p Distance to nearest: WellTota! length/size <br /> -s <br /> Foundation Property Line <br /> SEEPAGE PITS ❑ Depth _Size <br /> SUMPSNumber LL <br /> ❑ Distance to nearest: WellFoundation' <br /> DISPOSAL PONDS F1Property Line <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. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall 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 /> certifies the following:"1 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 /> The applicant m. cal all r quir d i Pe tions. Comple drawing on r rse side. <br /> Signed <br /> .Title: •�,.I <br /> _., ..,� . Date.- <br /> In <br /> ate: vl <br /> FOR EPARTMENT USE ONLY <br /> Application Accepted by <br /> Date Area j <br /> Pit or Grout inspection by <br /> Date Final Inspection by <br /> Date ' <br /> Additional Comments: c �'r!?�- �. <br /> 678 <br /> ❑ Stk 466- 1 ❑ Lodi 369-3621 ❑ Manteca 823- 104 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.❑Ha a on Averr,, P.O. Box 2009, Stk„ CA 95201 <br /> FEE AMOUNT DUE CK <br /> INFO AM NT EMITTED CASK RECEIVED BY DATE <br /> PERMIT NO. <br /> + EH 13-24(REV,t/a51 � ' <br /> EH 14-28 <br />