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APPLICATION.FOR PERMIT _ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE,, STOCKTON, CA <br /> Telephone (20g) 466_67., <br /> PERMIT EXPIRES 9 YEAR FROM DATE ISSUED <br /> Application is hereby (COmplete in-Triplicate) <br /> made in compliance with San Joaquin Coon <br /> p quip Local Health District fpr a <br /> Local Health District. q N Ordinance No, permit to construct and/or 111stali the work <br /> 549 for sewage or No. 1862 for weif/pump and the Rules and R <br /> herein described. This application is <br /> Job Address (� � / Regulations of the San Joaquin <br /> Owner's Name ���.L� � city <br /> � Lot Size <br /> Address W <br /> Contractor� l �T'� <br /> �S A <br /> TYPE OF WE ddress Phone <br /> NE.W WELL ❑ icense No. <br /> WELL <br /> PUMP INSTALLATION WELL REPLACEMENT ❑ W Phone <br /> DISTANCE TO NEAREST; DESTRUC7fON ❑ <br /> SEPTIC TANK <br /> YSTEM-REPAIR ❑.� <br /> FOUNDATION SEWER LINES OTHER ❑ <br /> DISPOSAL FLD. <br /> INTENDED USE ~ AGRICULTURE WELL PROP. LINE <br /> TYPE OF WELL PROBLEM AREA ~ OTHER WELL PETS/SUMPS <br /> ❑ Industria! ❑ Open Bottom CONSTRLICTjON SPEC)FICATlONS <br /> ❑ Domestic/Private ❑ Manteca Dia, of Wary Excavation C <br /> ❑ Gravel Pack ❑ Tracy Dia. of Weil Casing <br /> �dlPublie ❑ Other TYpe-Of Casing -S \yy " <br /> ❑ Irrigation C1 Delta Specifications <br /> Depth of Grou[Seal <br /> Repair Work Done ❑ ApProx. Depth ❑ Eastern ' " -t b �� , Type of Grout <br /> Type of Pump Surface Seal InsMIQ by.,/ <br /> Well Destruction � N.P. „„-� S <br /> ❑ Weil Diameter �pth , State Work Dane <br /> Sealing Material.(top 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ Filler Material`(Belo 5o'} <br /> REPAIR/ADDITION ❑ <br /> DESTRUCTION:❑ (Noavailable <br /> septic system permitted if public � <br /> Installation will serve: Residence � P � <br /> Commercial d" available within 200 feet.) p sewer is <br /> Number of living units: —' Other , <br /> Character of soil to a depth of 3 Number of bedrooms <br /> SEPTIC TANK Type/Mfg Water table depth <br /> - t <br /> f ' <br /> PKG. TREATMENT PLT. ❑ <br /> Capacity�� No Cam <br /> partments <br /> Distance to nearest; WellMethod of Disposal <br /> Foundation Property Line <br /> LEACHING LiNE ❑ No. & Length of lines <br /> FILTER BED ❑ Distance to nearest: Total length/size <br /> Well �9 <br /> Foundation <br /> Property Line J <br /> SEEPAGE PITS ❑ Depth <br /> SUMPS Size ` t. <br /> D Distance to nearest; Well�` Nuaber <br /> DISPOSAL PONDS ❑ Foundation . ,/ <br /> —!" Pro e <br /> � _R rty Line <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with h San Joaquin coon ordinances,rules and regulations of the San Joaquin Local Health District. � <br /> Home owner or licensed agent's signature certifies the following: county nances, state laws, and <br /> employ any person g such manner as to become subject to workman's compensation latus of California."Contractor's hiring or sub-contracting certify that in the Performance of the work for which this permit is issued, i shall not <br /> certifies the following: "I certify that into <br /> performance of the work for which this <br /> tion laws o{California." permit is issued, I shall employ acting signature <br /> The applic t must y. P Y Persons subject to workman's compensa- <br /> r re 'ed inspections. Complete drawing on rave j ide. � <br /> Signe a <br /> Title: J. i. <br /> 1 Date: <br /> FOR DEPARTM NT USE ONLY <br /> Application Accepted by <br /> Pit or Grout Inspection <br /> /17 <br /> Date Area <br /> Date /'EinI Inspection by ;. <br /> Additional Comments: V44 Date <br /> ❑ Stk .466-6781._.._......❑ Lodi 369-3621', i <br /> Manteca-B23-7104 _❑ 'racy 835,6395 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20og, Stk., CA 95201 <br /> FEE AMOUNT DUE r' <br /> INFO AMOUNT REMITTED f CK -"RECEIVED 8Y <br /> CASH GATE PERMIT N0. <br /> I <br /> 13-24(REV.I/e s) � w <br /> 11429 �0 " "'-f <br /> REM <br />