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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT -" <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> .PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (- <br /> .i (Complete in Triplicate) A 11'x. <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein descn e . <br /> 1 ion is <br /> or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage <br /> Local Health District. <br /> City <br /> O � - ( Lot Size PM <br /> Joh Address <br /> l b / Z , �/ v Phone <br /> Owner5 <br /> ,6 AliAddress <br /> 's Name r <br /> Address <br /> Phone <br /> License No. <br /> Contractor DESTRUCTION <br /> TYPE OF WELL/PU P: NEW WELL ❑ WELL REPLACEMENT ❑ <br /> ❑ _ . N <br /> 0. <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 11 - <br /> SEWER LINES D Fl D. PROP.:LINE <br /> DISTANCE AREST: SEPTIC TANK AGRICULTURE WE OTHER WELL PITS/SUMPS <br /> O N <br /> INTENDED USE TYPE OF WELL PRO NSTRUCTION SPECIFICATIONS <br /> CO <br /> Dia. o ation Dia. of Well Casing <br /> El Industrial Q Open Bottom anteca <br /> Q Tracy Type of Casing Specifications <br /> 0 Domestic/Private ❑ Gravel Grout Seal Type o <br /> Depth of Gro <br /> er � FI Delta Dep _ <br /> ❑ Public <br /> E I I Irrigation Approx., Depth 11 Eastern Surface Seal Installed by <br /> ' H.P. - --- _ – -------- ..State Work Done <br /> Repair Wor one ❑ Type of Pump Sealing Material'(top 50'1 <br /> Well De traction ❑ Well Diameter <br /> Depth 1 Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIRlADDITION L i DESTRUCT } asepticNo <br /> vailablewithin system <br /> feet.) it public sewer is <br /> Installation will serve: Residence Commercial— Other_-��.-- <br /> Number of living units: Number of bedrooms - <br /> = - +'�""�'" ""'"" Water table depth <br /> Character of soil to a depth of 3 feet: No, Compartments <br /> Mf <br /> ❑ Type/Mfg Capacity 0 <br /> SEPTIC TANK Method of Disposal <br /> r PKG. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well Foundation <br /> + Total-length/size <br /> LEACHING LINE 0 No. & Length of lines Property Line <br /> FILTER BED L) Distance to nearest: Well Foundation <br /> {I Number <br /> I SEEPAGE PITS l 1 Depth l Size <br /> ' Foundation Property Line <br /> SUMPS L] Distance to nearest: WeN <br /> I DISPOSAL PONDS ❑ 1 <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, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hire r <br /> certifies the following:"I certify that in the performansignature <br /> sub-contractt to workmanlscompensa- <br /> ce of the work for which this permit is issued, i shall employ-persons 1 <br /> tion laws of California." 1i 1 <br /> a <br /> The applicant must calltqr all required i . pections. Complete drawing on reverse side. <br /> Signed <br /> /,c.triQ it Tltie: Date: <br /> FOR DEPARTMENT USE ONLY <br /> J Date Area <br /> Application Accepted by _ : .... <br /> Date Final Inspection by ' Date' <br /> Pit or Grout Inspection :2L D ` <br /> Additional Comments: <br /> Ll Stk 466-6781 ❑ Lodi 369-3621 11 Manteca 623-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 <br /> CK RECEIVED BY DATE:_ PERMIT'NO. <br /> FEE AMOUNT,DUE AMOUNT REMITTED CASH <br /> INFO <br /> ♦.EH 13-241REV,W'15) S . CD <br /> EH 14-26 <br />