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s 4 <br /> " f APPLICATION FOR PERMIT <br /> . �r <br /> . SAN JOAQUIN LOCAL_ HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> all the work <br /> catiO <br /> A adeCrn comp)once wntlhade to the San Joaquin San Joaquin Cois <br /> unty OrdinalHealth District for a nce No.549 for sewage or INo. 1862 forto cwell tlpump and the Rul s and IR gulationdescribed. <br /> of the SanThis l Joaquin <br /> m <br /> Local Health District. <br /> AxJ City S'77C_AJ Lot Size A0Abt:_10 0 PM <br /> Jab Address � <br /> Phone - <br /> Owner's Name. ���M ����, ' �� Address 1D 3 9p � <br /> • <br /> Contractor � Address <br /> 06- <br /> License No.4��y�y Phone 46 �37 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑.-.-_- OTHER ❑ <br /> -' ' <br /> SEWER LINES <br /> DISTANCE TO NEAREST:-SEPTIC TANK" <br /> r -:-DISPOSAL FLDr - PROP. LINE <br /> FOUNDATION AGRICU WELL OTHER WELL PITS/SUMPS <br /> Il INTENDED USE i TYPE OF WELL PRO AREA CONSTRUCTION SPECIFICATIONS s Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom Manteca Dia. of Well Excavation i <br /> T e of Casing Specifications <br /> ❑ Domestic/Private ❑ Gravel Pac ❑ Tracy Type 1 <br /> i Depth of Grout Seal Type of Grout — <br /> {1 Public t l Othe `` (=l Delta <br /> I I Irrigation ° Approx Depth I 1 Eastern Surface Seal Installed by <br /> 1 H p State Work Done } <br /> Repair Work Done ❑ ype of Pump I { <br /> Well Destruction ❑ 'Well Diameter Sealing Material (top 50'1 r <br /> I Ir: <br /> Depth Filler Material-{Below 50'1 <br /> TYPE OF SEPTIC WORK: !NEW INSTALLATION I I REPAIR/ADDITION 1. 1 DESTRUCTION aNailabptic syiithi n 200 emitted if public sewer is <br /> 4 eetJ 1- <br /> Installation will serve: Residence� Commercial— other e . <br /> Number of living units: Number of bedrooms , Water table depth r. <br /> Character of soil to a de11' 0 3 feet: <br /> Capacity No. Compartments <br /> SEPTIC TANK L1Type/Mfg Method'of Disposal / <br /> PKG. TREATMENT rPLT. ❑ t ' <br /> "i' Property Line <br /> Distance to nearest: Well Foundation <br /> LEACHING LINE ❑' No. & Length of lines t Total length/size <br /> . Foundation Property * . <br /> FILTER BED ❑'z Distance to nearest: Well PrertLine <br /> I <br /> s1 <br /> ;Size # Number <br /> SEEPAGE PITS Depth'. <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line t <br /> DISPOSAL PONDS El' <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. i <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 peosons ring or subject to workman'Isgsignature <br /> compensa- <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,l shall employ p 1 <br /> FF tion laws of California." <br /> C The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Date: <br /> + Title: 3 <br /> Signed X r i <br /> g ,+_.FOR�DEPPJARTMENT_.U$E ONLY_. Q <br /> Date y 4,Airea <br /> Application Accepted by <br /> Q)') <br /> Pit or Grout Inspection <br /> t Date ~} Final Inspection by Date �fQ <br /> E <br /> Additional Comments: <br /> " ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant . Return all copies to: Environmental Health Permit/services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> I i . <br /> FEE C RECEIVED BYRan <br /> INFO AMOUNT DUE AMOUNT REMITTED SH <br /> 3S�d <br /> a EH 13-241REV.1/851 <br /> 1:H 14-26 <br />