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(ji5l <br /> APPLICATION FOR PERMIT ' ` <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT" <br /> j <br /> 1601 E. HAZE I ON AVE-, STOCKTON CA - <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Tril5licate) <br /> Application is hereby made to the San Joaquin Local Health District for.a permit to construct andlor-install the work herein described. This application is <br /> Applicaunty Ordinance No. 549 for sewage or No. 1862 for well/Pump and the Rules and Regulations of the San Joaquin <br /> made compliance with San Joaquin Co <br /> Local Health District. /. <br /> r <br /> g w r� <br /> City Lot Size PM. <br /> Job Address C� ? <br /> Address 71vo Phone <br /> . <br /> Owner's Name- '._ <br /> Address �° License NoAC `l/ __Phone <br /> Contractor <br /> TYPE OF WELLIPUMP: _ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP IIVSTALCAT101V'C7 � SYSTEM FtP41F1 ❑ OTHER 12 <br /> SEWER LINES DISPOSAL F P_. LINE r <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL— <br /> INTENDED <br /> PITSI;SLFMPS } <br /> FOUNDATION AGRICULTU �,Y� N <br /> INTENDED USE TYPE OF WELL P AREA CONSTRUCTION SPECIFICATIONS ! ' <br /> (Specifications <br /> pia. of Well Cas+ng v1 <br /> ❑ Industrial ❑ Open Botto ❑ Manteca Dia. of Well Excavation { r __ <br /> �"�-T e of Casing 5pecificatio s - <br /> ❑ Domestic/Private ❑ Grr ack ❑ Tracy Yp } r <br /> " 3th of Grout Seal Typeof Grout <br /> I 1 Public ❑ her, `"-❑ Delta.}. „� p <br /> De <br /> I I Irrigation <br /> _.ApproxJDepth' I i Eastern '.Surface-Seat Installed by <br /> State Work Done <br /> Repair Work Done ❑ Type of Pump ' H.P. <br /> Sealing Materia .(top 50') <br /> Well Destruction ❑ Well Diameter 9 4 ' <br /> epth 'Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK a EVgANSTAL-L-ATION-[-:]—"REPAIR/ADdITIQN Ll DESTRUCTIQN (No Pet <br /> avasept <br /> ic <br /> system <br /> feet.) <br /> 1 intallation will serve esidehce�" Commercial OtherNumber of living uni Nu"6r of bedrooms W <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> I <br /> jj t Method of.Disposal' <br /> PKG. TREATMENT-P'T. ❑ t - <br /> fPro Property Line <br /> Distance to nearest: Well Foundation P Y <br /> i 7 <br /> LEACHING LINE ❑ No. BiLength of lines Total length/size ' �} <br /> FILTER BED ❑ Distance to nearest: Well s Foundationr Property Line , <br /> i' <br /> N <br /> ` Size t J umber ) <br /> SEEPAGE PITS l I Depth } <br /> SUMPS L� Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑- k <br /> I hereby certify that 1 have prepared thisapplication'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: "1 certify that in the performance of the work for which this permit is issued, l shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature <br /> I certifies the fallowing: "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 st call for'_all required inspections. Complete drawing on raver <br /> Date: <br /> Signed Title: <br /> FOR PARTMENT USE ONLY ' <br /> 13 —Date '� t 7 Area <br /> Application Accepted by44 <br /> Date Final Inspection by 1 Date <br /> Pit or Grout Inspection by d ' <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE CK RECEIVED BY DATE PERMIT'NO. <br /> i INFO AMOUNT DUE AMOUNT REMITTED <br /> r l Vil 0 <br /> + EH 13-241REV.I/v.51 <br /> EH 14-26 ��JJJJ <br />