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I . <br /> i' APPLICATION FOR PERMIT <br /> r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466_6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to the San <br /> (Complete in Triplicate) 1��0 <br /> Joaquin Local Health District for a permit to construct and/or install the work <br /> made o.549 for sewage or No. 1862 for well/ <br /> compliance with San Joaquin County Ordinance Npump and the Rules and Regulations of the San Joaquin~_ <br /> Local Health District. herein described. TMs application <br /> Job Address� <br /> City Lot Size <br /> PM <br /> Owner's Name <br /> Address <br /> done <br /> Contractor's Name <br /> TYPE OF WELL/PUMP: License No. <br /> NEW WELL ❑ Phone <br /> WELL REPLACEMENT Ll ' <br /> PUMP INSTALLATION ❑ DESTRUCTION ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK Y SYSTEM REPAIR ❑ OTHER ❑ <br /> SEWER LINES � <br /> DISPOSAL FLD. <br /> ` FOUNDATION AGRICULTURE WELLfPROP. LINE <br /> INTENDED USE- OTHER WELL PITS/SUMPS <br /> TYPE OF WELL PROBLREA_CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial 11Open.Bottom <br /> ❑ Manteca Dia: of Well Excavation <br /> ❑ Domestic/Private _ ❑ Gravel Pack",. Dia. of Well Casing <br /> r ❑ Tracy t Type of Casing <br /> ❑ Public ❑ Other ❑ Delta Specifications <br /> ❑ Irrigation Depth of Grout Sea! <br /> Approx. Depth ❑ EasternSeal' <br /> Type of Grout <br /> Repair Work Done ❑ T Surface Seal'installed by <br /> Type of Pump H.P. �' 09 <br /> Well Destruction State Work Done <br /> ❑ Well Diameter Sealing Material (top 50') �V*1 <br /> Depth Filler Material (Below 501) Xk. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L <br /> k, REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> A Commercial_ Other <br /> 4 V� <br /> Installation will serve: Residence r available within 200 feet.) <br /> —�� <br /> Number of living units: Number of bedrooms _ 1 <br /> Character of soil to a depth of 3 feet: <br /> VN <br /> ❑ IliType/Mfg k <br /> SEPTIC TANK 1 Waier table depth <br /> PKG. TREATMENT PLT. ❑ �Capaclty­-Z-9—C-147—No. Compartments 1'2-- <br /> Distance to nearest: Well � Method of Dlspo 1 0 <br /> �L�� Foundation Property Line <br /> LEACHING LINE K No. & Length of lines <br /> FILTER BEDa Total length/size <br /> ❑ Distance to nearest: Weil Foundation (0 <br /> —�12_ C Property Line <br /> SEEPAGE PITS <br /> ❑ Depth lr <br /> Size � Nu�1 er � Q <br /> SUMPS El / <br /> Distance to nearest: Well 9 f <br /> DISPOSAL PONDS ❑ Foundation ! property Line <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 J <br /> rules and regulations of the San Joaquin Local Health District. ` <br /> Home owner or licensed agent's signature certifies the following: <br /> ., <br /> that employ any person in such manner as to become subject to workman's compensation Ithe w soof California."Contractor'srmance of the work for )h gingch )apsub cont ecermit is ti glsh <br /> signaltnot r <br /> certifies the following: # <br /> "I certify that in the performance of the work for which this permit is issued, I shat!employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call hDr all required ' ns. Complete drawing on reverse side. <br /> Signed <br /> Title Date: <br /> t <br /> FOR DEPARTMENT DISE ONLY <br /> Application Accepted by CIL/ Q� <br /> Date Area <br /> Pit or Grout inspection by pate <br /> Final Inspection byA3e,�� Date �U <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 (� <br /> Applicant- Return all copies to: Environment ealt Permit/Services 1601 EHazelton Ave., P O. Box 2009, Stk., CA 952 1 � <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT`NO. <br /> EH 13-24(REV.10183) <br /> EH 1428 S c� `,il 'J<e <br />