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APPLICATION",FOR PERMIT " <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE,,_TON AVE., STOCKTON, CA <br /> Telephone (209) 466-67$1 <br /> 4nEMIT EXPIRES.1 YEAR FROM DATE ISSUED . . <br /> (Complete in T(plicate) application is <br /> or'install the work <br /> Application is hereby made to the u nnJoaquin Local Health Couniy 0 dirlance No District549 for sewage or permit <br /> No. 1562 for well/ ump and the Rules and(Regulations of he San Joaquin <br /> made in compliance with San JoaoL <br /> Local Health District.. <br /> City � Lot Size PM <br /> l 3' i — <br /> Job Address ` ko /_ 1�D Phone- <br /> Owner's Name _ <br /> Phone <br /> ` lti ddress ' <br /> �Q <br /> dln�� _ Phone <br /> Contractor's Name License No.WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ be OTHER ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR <br /> SEWER LINES __�--- DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK �. — OTHER WELL PITS/SUMPS <br /> FOUNDATION __� AGRICULTURE WELL <br /> r <br /> ELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF W _ Dia. of Well Casing _ <br /> ❑ Industrial --❑-Open Bottom_ Gl Manteca -Dia. of-Well Excavation - Specifications <br /> Domestic/Private Y A ElGravel Pack ❑ Tracy Type of Cas1ng- y 10 _ . .. - <br /> T -O.other ❑ Delta <br /> ! ! Depth of Grout Seal Type of Grout_�---- <br /> C] Public <br /> --Approx. Depth Eastern Surface Seat Installed by— <br /> ❑ Irrigation <br /> Repair Work Done ❑ Type of Pump OuAg <br /> H P State Work Done <br /> Sealing Material !top 50'! t <br /> Well Destruction L1 Welt Diameter �� Filler Material (Below 50') <br /> l Depth U1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ aNailablelwithin 200 feettjed if public sewers J <br /> Installation wiH serve: Residence— Commercial— Other � <br /> Number of living units: Number of bedrooms `u ir. Water table depth <br /> Character of soil to a depth of 3 feet: Capacity�..� No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Foundation —� property Line <br /> I Distance to nearest: Well :---le <br /> Total length/size <br /> LEACHING LINE C1No. & Length of lines <br /> 'Foundation— Property Line <br /> FILTER BED ❑ Distance to nearest: Well tf� <br /> i <br /> Number <br /> SEEPAGE PITS ❑ Depth Size <br /> iProperty Line <br /> SUMPS ❑ Distance to nearest: -Foundation on 1 •t,� <br /> I DISPOSAL PONDS ❑ <br /> hereb 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 /> Y <br /> rules and regulations of the San Joaquin Local Health pistrict.g <br /> compensation laws of California."Contractor s hiring or sub-contracting signature <br /> Home owner or licensed agent's signature certifies the following: 9 certify that in the performance of-the work for"which.this permit is issued, l shall no <br /> employ any person in such manner as to become subject to workman's compo rsont"subject to workman's compensa- <br /> empl es the following:"I certify that in the performance of the work for whcertiich this permit is issued,I shall employ�pe � <br /> tion laws of California." <br /> r <br /> The applicant t call f all requlr d in pe ins. Complete drawing on rev4rseC b Date. <br /> - Title: ;;VVii Mia <br /> Signed <br /> FOR DEPARTMENT USE ONLY 1r�>' <br /> / Date Area—�---- <br /> Application Accepted by Date- <br /> Date— Final Ins <br /> Pit or Grout Inspection by <br /> pection by t <br /> F <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 535&moi f <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT REMITTED <br /> CK RECEIVED 8Y ` DATE PERMIT`NO. <br /> INFO AMOUNT DUE GASH <br /> + EH 13-241REV.101831 <br /> EH 14-28 <br />