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APPLICATION-FOR PERMIT / <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> L <br /> TON AVE., STOCKTON, CA <br /> 1601 E. HAZE <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1"YEAR FROM DATE "ISSUED <br /> (Complete in Triplicate) <br /> �i <br /> cation is <br /> Application is hereby made to the Sarnui Ordinance No.District549 for sewage or permit <br /> No 1862 for ell/pump and the Rules and Regrein ulations of the San.This l Joaquin <br /> made in compliance with San Joaqu County <br /> Local Health Distrkf. i <br /> "� TLS/ � City �� Lot Size � <br /> Job Address 1 _ �- 3 a� if <br /> _ Phone 9 <br /> Address 0 D <br /> Owner's Name ? <br /> License No. —�—Phone ! <br /> " Address <br /> Contractor WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELLIPUMP: NEW WELL LJOTHER ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR © -1 <br /> SEWER LINES <br /> DISPOSAL OP. LINE <br /> �� _ <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL ER WELL PITS/SUMPS <br /> t FOUNDATION �— <br /> F RUCTION SPECIFICATIONS <br /> k INTENDED USE TYPE OF WELL PROBLEM AREA Dia. of Well Casing <br /> ❑ Open Bottom ❑ Man Dia. of Well Excavation i <br /> ❑ Industrial Specifications <br /> k ❑ Gravel Pack racy Type of Casing <br /> ❑ Domestic/Private Type of Grout <br /> ❑ Other ❑ Delta 4 Depth:of Grout Seal <br /> }" <br /> L7 Public Surface Seal Installed by ` <br /> El Irrigation - pprax. Depth L) Eastern State Work:Done it' <br /> Repair Work D <br /> Type of Pump �— . HPstate I <br /> Sealing Material )top 50'1 ; <br /> --. W ruction ❑ Well Diameter ;Filler Material Ieelow 501 ; <br /> Depth <br /> available within 200 feet.) <br /> } TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> Installation will serve: Residence— Commercial—�Other <br /> a <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal ¢ r� <br /> PKG. TREATMENT PLT. ❑ Foundation Property Line <br /> Distance to nearest: Well t <br /> :A <br /> I "Total length/size <br /> LEACHING LINE ❑' No. & Length of lines <br /> FILTER BED ❑ Distance Pro Line ~' <br /> I to nearest: Well Foundation pem' <br /> �~ <br /> � � F <br /> Size Number <br /> SEEPAGE PITS ❑" Depth Property Line <br /> SUMPS <br /> .C1 Distance to nearest: Well Foundation s_- <br /> DISPOSAL PONDS ❑ ' <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 /> G rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I signature <br /> shall not <br /> I r's hiring o <br /> employ any person in such manner as to becomesubject to workman's <br /> he work for wh ch this perm t is issuedcompensation laws of ,shall employ persons subject to workman's gcompensa- <br /> certifies the following: "I certify that in the pe <br /> j tion Maws of California." <br /> a The applicant st call for all required inspections. Complete drawing on reverse"side. 1 r�� <br /> o Date: <br /> Title: <br /> Signed X <br /> �U_ <br /> �_ _ <br /> NT USE ONLY a �l <br /> --- — Date Area 0 <br /> e <br /> Application Accepted by Data <br /> I Date Final Inspection by <br /> 1 Pit or Grout Inspection by <br /> Additional Comments: <br /> ❑ Stk 466-6781 D Lodi 369-3621 ❑ Mante 823-7104 ❑ Tracy 835 6385 <br /> L Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CK RECEIVED BY DATE PERMIT NO. <br /> FEE AMOUNT DUE- AMOUNT REMITTED CASH <br /> INFO <br /> + <br /> EH 13-24(REV.I <br /> EH 14-26 y <br />