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APPLICATION FOR PERMIT <br /> SAN JOAaU1N,LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE.,.STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> t and/or'3- <br /> cation is <br /> t to <br /> Application is lance with Sano the Joaqu n County OrdinanHealth ce No.District49 for sewage or'No 1862 forcwell/pump and the Rules and Regulations of ifle San all the work her�in describe�',This l Joaquin <br /> made in compliance - e <br /> Local Health District. ,. <br /> - <br /> City Lot Size PM <br />` Job Address - r <br /> Phone <br /> Address <br /> Owners Name <br /> Address License Na. Phone <br /> O : �- <br /> I <br /> Contractor «t " DESTRUCTI <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL AEPLACEMENT, .,_ �", w <br /> i -SYSTEM-REPAIR-© OTHER-❑ <br /> . .PUMP INSTALLATION-❑�-- r- -� DISPOSAL FLD. PROP, LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF'WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r Dia. of Well Casing <br /> 0 Industrial ❑ Open Bottom ❑ Manteca bia�of N7ell Excavation Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing y <br /> 3 ❑ Delta Depth of Grout Seal Type of Grout <br /> E] Public ❑ Other i <br /> El Irrigation �0.Pprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done LlType of Pump H.P. State Work Done <br /> ' Sealing Material (top 50'1` ' <br /> Well Destruction ❑ Well Diameter -.F <br /> I Filler Material (Below 50 <br /> Depth '1 <br /> o sept <br /> t UCTION TYPE OF SEPTIC WORK: NEW INS TALLATION ❑ REPAIRIADDITION C1DESTRalvailable�wthin 200 feet.) if public sewer is <br /> Installation will serve: Residence Commercial— Other <br /> Number of bedrooms ,rte- - --T---r °'^"_ate <br /> � Number of living units: Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK % Type/Mfg Capacity�� <br /> F ,� Method of Disposal <br /> PKG. TREATMENT PLT. ❑ + f*` ` <br /> Distance to nearest: Well <br /> K Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total,length/size <br /> FILTER BED L3 Distance to nearest: Wel! <br /> Foundation. Property Line <br /> Size Number <br /> SEEPAGE PITS [I Depth <br /> ( Foundation Property Line <br /> SUMPS ❑ Distance to nearest: Well <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.. <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, 1 signature <br /> shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contremploy <br /> persosnsiring of subject t workman's eompensa- <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ p <br /> tion laws of California." . <br /> The applicant must call for all required inspecti ns. Gomplete drawing on reverse side. <br /> Title:, <br /> Date: <br /> Signed <br /> FOR DEPARTMENT USE ONLY <br /> Date /� -� g� rea 028 <br /> Application Accepted by�e <br /> Da <br /> 1 Final in pection by Date <br /> k 9"k Pit or Grout Inspection by date , <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 69-3621 ❑ Manteca. 823-71 .❑ Tracy 8355-6385 <br /> Applicant- Return all copies to: EnvironmentalHealthPermit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CK RECEIVED BY DATE PERMIT'NO. <br /> FEE - AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> + EH 13-24(REV.1/ 5) <br /> EH 14-25 ,_ -- - <br />