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a <br /> APPLICATION FOR PERMIT 6_f ,3 Y3 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL—I ON AVE., STOCKTON, CA <br /> Telephone (209} 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I (Complete in Triplicate) 41 <br /> ))cation is l <br /> App Ordinance No.549 for sewa or No. 1662 for woupump and the Rules and Regulations of the San Joaquin F <br /> Application is hereby made to the San Joaquin Local Health District for a permit t°construct anWor install the work herein described. This app <br /> made in compliance with San Joaquin County P <br /> ocal Health District. &MV <br /> ! Lot Size PM_�-- <br /> D4 City <br /> Job Address j <br /> Phone <br /> Address <br /> Owner's Nam w i <br /> License No.��.�phone_ r <br /> L Address <br /> ontractor WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF W7 LLIPUMP: NEW WELL ❑.- OTHER_❑ <br /> SYSTEM REPAIR ❑ PROP, LINE <br /> PUMP INSTALLATION ❑ DlSP <br /> SEWER LINES �— PITS/SUMPS <br /> DISTANCE <br /> TO-NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL Q p <br /> FOUNDATION l� 1 <br /> PflOBLEM AREA STRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL Dia. of Wel! Casing <br /> Dia. of,Well Excavation <br /> QD <br /> O Industrial ❑ Open Bottom ❑ M Specifications \J\),.\ <br /> ❑ Gravel Pack Tracy Type of Casing h V� <br /> ❑ Domestic/Private Type of Grout <br /> Fnl Othe n Delta Depth of Grout Seal <br /> FI Public , Surface Seal installed by <br /> I I Irrigation __._--Appfo Depth I I Eastern State Work Done <br /> `r H.P. <br /> Repair Work Do Type of Pump � <br /> i Sealing Material (top 50'1 <br /> I Well Destr ction C1 Well Diameter —� <br /> ' Depth Filler Material (B--- <br /> available within 200 feet.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION�l I DESTRUCTION o septic system permitted if pu <br /> lNhlic sewer is <br /> Installation will serve: Residence <br /> Commercial— Other--- <br /> Number of living units: Number of bedrooms L. Water table depth <br /> r <br /> Character of soil to a depth of 3 feet: Capacity_--- No. Compartments <br /> SEPTIC TANK ❑ Type/Mig tl Method of Disposal. <br /> PKG. TREATMENT PLT. ❑ `F ch ridatiori"� s'-.Property Line <br /> Distance to nearest: Well <br /> Total length/size <br /> l ❑ No. & Length of lines <br /> LEACHING LINE � -- .w ""'Fbtlndation��— PfOperty Line <br /> # FILTER BED ❑ Distance to nearest: Well <br /> r Sr <br /> Number <br /> SEEPAGE PITS I I 'Depth 4 Size Foundation Property Line , <br /> SUMPS L�. Distance to nearest: Well <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that Y 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 Sari Joaquin Local Health District. a work tor g <br /> not <br /> Home owner or licensed agent's signature <br /> become subjec�lto wEorkman'srtcompensation lfy that in the aws of-California." Contractor srhuingl or sub-contracting compermit is issued, I ensa- <br /> employ any person in such manner a. f <br /> certifies the following-:'I certify'ihaf in-the performance of the work for which this permit is issued, I shall employ persons subject t°workman's compens - <br /> tion laws of California." P e <br /> The applicant must call for all re fired inspections. Complete drawing on reverse side. Date: <br /> Title: <br /> Signed 3C + <br /> •FOR DEPARTMENT USE ONLY � 1 �� i <br /> Date Area <br /> Application Accepted by Date <br /> �,ca <br /> ��-- F a Inspection VPit or Grout Inspection byAdditional Comments: ❑ M823-7104 ❑ Tracy 835-6385 <br /> ❑ Stk q6b 6781 ❑ Lodi -3621Stk., CA 95201 <br /> r Applicant Return all copies t� Envir nment I Heal h Perm' ervlce 1601 E. Hazelton Ave., P.O. Box 2009, f <br /> RECEIVED BY HATE PERMIT NO. <br /> FEE ` AMOUNT DUE AMOUNT REMITTEO CASH / <br /> INFO <br /> ..EH 13-24 4REV.1 i H 51 <br /> EH 14-2e <br />