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APPLICATION FOR PERMIT 7 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT or C <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 - <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> -for a <br /> and/or install the work <br /> Application is hereby made <br /> toJoaquin the San Jo <br /> County O�dinalnce No. 549 for sewage o(Health DistrictNo. 1862 for t to construct <br /> and the R les and herein <br /> gulations of This application <br /> San Joaquin <br /> made in compliance with i <br /> Local Health District. <br /> ►rGS t �4 � f City /n <br /> Job AddressLot Size -71PM <br /> .3Z C / O� <br /> Ownerfh ne �2Cg�5 <br /> 's Name Address <br /> tJ cense No..i4 Phone <br /> Contractor eS. Address o�7�-5a <br /> TYPE OF WELLIPUMP: NEW WELL � WELL REPLACEMENT EJDESTRUCTION ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ .. <br /> SEWER LINES DISPOSAL FLD. PROP. LINE L� <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack LlTracy Type of Casing <br /> l'1 Public n Other <br /> n Delta Depth of Grout Seal Type of Grout <br /> —..Approx. Depth I 1 Eastern Surface Seal Installed by >� <br /> I ! I Irrigation State Work Done <br /> Well Destruction Ll Well Diameter <br /> r Repair Work Done ❑ Type of Pump H.P. <br />{ Sealing Material Itop 50'i <br />� <br /> Depth Filler Material (Below 501 <br /> l <br /> " TYPE DF SEPTIC WDRK: NEW INSTALLATION I REPAIR/ADDITION i l DESTRUCTION I I (Nailseptic <br /> able w hit system <br /> per <br /> fitted if public sewer is <br /> l <br /> 4 <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: _,L_ Number of pedroomis Water table depth r Q f <br /> ! Character of soil to a depth of 3 feet.' Z <br /> elMi -� Capacity 4� No. Compartments <br /> SEPTIC TANK �TYP g Method of Disposal <br /> PKG. TREATMENT PLT.❑ Property Line <br /> ! Distance to nearest: Well_49-a— Foundation <br /> LEACHING LINELNo. & Length of lines <br /> Total lengthlsize <br /> I FILTER BED ❑ Distance to nearest: Well � Foundation <br /> Property Line_lam_--- <br /> Number <br /> Size <br /> SEEPAGE PITS i31 Depth Property Line <br /> i SUMPS L) Distance to nearest: Well O Foundation P rtY <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 /> 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 the work for which this permit is issued, I 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 /> 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 /> f The applicantt c II for inspections. Complete drawing on reverse side. <br /> Signed X <br /> Title: a �" Date: <br /> FOR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by <br /> it r Grout Inspection by "� 'C�at �— Final Inspection by <br /> I � <br /> Additional Comments: �— / r- <br /> I ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca -7104 � ❑ Tracy 835-5385 <br /> h Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> Applicant- Return all copies to: Environmental Healt <br /> FEE RECEIVED BY DATE PERMIT NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED <br /> ' +.EH13-241REV.I/N51 <br /> EH 14-26 <br />