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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> {Complete in Triplicate} <br /> cation is <br /> all the work herein des <br /> Application is hereby made oJoaquin San <br /> Cou Qty Ordinance <br /> No. 549 for sewage or permit <br /> 1862 for cwewpump and the RRules and R gulations of tthe Sanis s Joaquin <br /> made in compliance with San <br /> Local Health District. <br /> City gF-3GPp Lot Size PM <br /> Job Address .2 <br /> s dG Phone <br /> i Owner's Name G( �1 ddress / <br /> 51911" - !�5 0�7� License No. Phone <br /> X Contractor A V.� � Address DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WE REPLACEMENT WELL ❑ STEM REP ❑ � OTHER ❑ <br /> PUMP INSTALLATION Ll <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> ' FOUNDATION AGRICULTURE LL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONS UCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial [I Open Bottom Ll Manteca Dia. f eU Excavation <br /> T e of C ing Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Grout <br /> l'1 Public ❑ Other J( ❑ Delta epth of G ut Seal <br /> I I Irrigation —Approx. Depth l I Eastern Surface Seal' stalled by <br /> Type of Pum H.P State Work Done <br /> Repair Work Done ❑ TYP r P <br /> Well Destruction El Well Diameter eking Materia! Stop 50'1 <br /> f Depth I Filler Material (Below 50'1 se <br /> 1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAkRIADDITION I I DESTRUCTION I 1 available within system <br /> m feet.] if public sewer is <br /> Installation will serve: Residence Commercial— Other " <br /> t <br /> Number of living units: 4 Number of bedrooms— — <br /> - Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments 2- <br /> SEPTICTANKType/Mfg Capac;ty <br /> PKG. TREATMENT PLT. ❑ Method of Disposal G <br /> D;starice to nearest: Well Foundation Property Line <br /> L <br /> t <br /> LEACHING LINE K No. & Length of lines Total length/size <br /> FILTER BED EI Distance to'nearest: Well Foundation Property Line <br /> SEEPAGE PITS l 1 Depth, Size Number <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> SPOSAL PONDS ❑ <br /> in and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have preparedthis applicatio <br /> r 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 thework for which this permit;s issued, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."a."Contractor's hiring or sub contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mint call for all requir inspe ions.Complete drawing on reverse side. <br /> 4 Date: <br /> Signed X <br /> Ki FOpRTMENT USE ONLY �l <br /> t , <br /> R <br /> Area <br /> Application Accepted by u <br /> Date <br /> Inspection by <br /> Pit or Grout Inspection by Date � <br /> r <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 3-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmen al Health Permit/Services 1601 E. Hazelton Ave., P.O. pox 009, tk., CA 95201 <br /> (Au- , L_� ed'- Ill <br /> FEEMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO. <br /> INFO !.� <br /> r ♦ EH 13=24ARE�i i H 51 -7V � o n <br /> EH 14-2e <br />