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i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ­ f <br /> 1601 E.'HAZELTON AVE., STOCKTON, CA RECETV" <br /> Telephone-(209) 466-6781 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED Ali + O ���a <br /> (Complete in Triplicate) <br /> he R-0 i�f}* _-Vication is <br /> PEW <br /> fhe San Joaquin <br /> lc7yli'1�'fJL�� <br /> uin Local Health District for a permit to construct and/or install t <br /> Application is hereby made to the San Joaq 'CrJ <br /> ty Ordinance No.549 for sewage or No. 1862 for well/pump and the R <br /> made in compliance with San Joaquin Counue <br /> Local Health District. w . <br /> City. 1'M <br /> Job Address i <br /> i. Phone u <br /> �,U!r Address <br />'k Owner's Name ' <br /> /� ense No. Q phone <br /> Contractor DESTRUCTION a" Address. (!c'� — <br /> WELL REPLACEMENT ❑ DESTRUCTION Ll <br /> TYPE OF WELL/PUMP: NEW WELL ❑ OTHER 6t <br /> 4 PUMP INSTALLATION <br /> Ll <br /> REPAIR ❑ <br /> . SEWER LINES DISPOSAL FLD. PROP. LANE <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS Y <br /> FOUNDATION AGRICULTURE WELL <br />_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l]ia of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> F Type of Casing -- <br /> ip.Domesticl [D Gravel Pack ❑ Tracy Depth of Grout Seal Type-of Grout <br /> Other ❑ Delta <br /> f _ <br /> i'1 Public Surface Seal Installed by <br /> I Irrigation App14t � <br /> roxi D tep h l i Eastern grate Work (Jona <br /> x; State— H. . <br /> Type . c <br /> Repair Work Done Te of P <br /> Well Destruction d Well Diameter <br /> Sealing Material (top 501 <br /> Depth I Filler Material (Below 501 <br /> setTYPE OF SEPTIC WORK: NEW INSTALLATIaN I. REPAIRlADDITION l I DESTRUCTION i l availabpelwi hin 200 feetsystem .) if public sewer is <br /> Installation will serve: Residence ''Commerciale Other I <br /> ' t�= <br /> Number of living units' Number of bedrooms Water table depth <br /> I Character of soil to a depth of 3 feet: <br /> ❑ Type/Mfg —..-T <br /> Capacity ' t No. Compartments ' <br /> f <br /> SEPTIC TANK F � T Method of Disposal <br /> I PKG. TREATMENT PLT.D- I Property Line <br /> I - Distance to nearest: Well Foundation P Y <br /> Total lengthlsize <br /> F LEACHING LINE CI No. & Length of lines + <br /> ! ' Foundation Property Line <br /> FILTER BED 0 Distance to nearest: Well <br /> J I Depth <br /> I Size _ Number <br /> SEEPAGE PITS Foundation Property tine <br /> SUMPS [.l Distance to nearest: Well <br /> f' DISPOSAL PONDS ❑ <br /> 1 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 Distfict.g <br /> I. <br /> following: I certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agents signature certifies the <br /> employ any person in such manner as to become subject to workman's compensation laws of California."employ <br /> p6osonslsubject to workman'scompansa <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ p 1 <br /> tion laws of California." i <br /> I The applicant must call for required inspections. Complete drawing on r rse side. <br /> +� Date: <br /> Signed X Title: <br /> F RD ARTMENT USE ONLY <br /> Date r e— <br /> Application Accepted by Data ,�r <br /> Data Final Inspection by <br /> Pit or Grout Inspection by <br /> f Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca 823-7104 Tracy 835-6385 <br /> I Applicant - Return all copies to: Environmental Health Permit/Services 1601'E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> rRECEIVED BY DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> E INFO � <br /> ` .,EH 13-24(REV.1/951 <br /> f. EH 14-26 ' - <br /> Ft 1 <br />