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�Y <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT H <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> .Telephone 12091 466-6781 <br /> PERMIT EXPIRES 7 YEAR FROM DATE ISSUED'` •i ''V ' +'� <br /> (Complete in Triplicate) <br /> xrsj, <br /> istri <br /> made <br /> Application <br /> hereby wimade to the th San Joaquin Joaquin Ordinance lHealth No.549 for sewage or permit <br /> 1862 for well//pump and the R41 s and/or install the work �Regulatioons of the Sang Joaquin <br /> made in compliance - ° �E <br /> Local Health District. <br /> ` li <br /> City <br /> '#- Lot Size PM <br /> Job Address :. <br /> hone <br /> Owner's Name h Address <br /> Contractor <br /> Address License No. Phone <br /> WELL REPLACEMENT ❑ DESTRUCTION <br /> TYPE OF WELL/PUMP. NEW WELL ❑ SYSTEM REPAIR ❑ OTwER ❑ <br /> PUMP INSTALLATION r.7 <br /> DISTANCE 70 NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD.W- PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS-. ,_ <br /> -"�- Dia. of Well Casing <br /> E3 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> ❑ Domestic/Private ❑ Type of Casing Gravel Pack ❑ Tracy of Grout <br /> ❑ Delta Depth of Grout Seal _ -__Typer <br /> ❑ Public_ ❑ Other s �� __.. - <br /> ❑ Irrigation_ _ .- -^� '_JApP�ox6ept}i;'❑ Eastern Surface Seal Installed by I <br /> Y j H P State Work Done <br /> Ik Repair Work Done El Type of Pump - <br /> Well Destruction ❑ Well Diameter_� -- Sealing Material (top 501 <br /> " Depth Filler Material (Below 501) <br /> i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION <br /> ❑ DESTRUCTION ❑ aNaiiabpe�within 200 feetitted if public sewer is <br /> Installation will serve: Residence Commercial, Other <br /> i � • <br /> Number of living units: Number of bedrooms Water table depth ^ e <br /> f Character of soil to a depth of 3 feet �^� :- <br /> "'• i Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg J,, Method of Disposal <br /> PKG. TREATMENT PITT. ❑ I �I y <br /> Foundation Property Line <br /> ""`"�`pistance.to-nearest:.. Well { <br /> _ r <br /> Total lengthlsize 4 <br /> LEACHING LINE El No. & Length of lines Property Line <br /> FILTER BED C1Distance to nearest: Well Foundation V <br /> i <br /> r <br /> ,Number-�- -. <br /> SEEPAGE PITS —0—Depth -�� ••_: ..�__._eSize -- -- ------ -• <br /> s Foundation - Propert4 Line <br /> SUMPS ❑ r Distance to nearest: <br /> Well - <br /> DISPOSAL PONDS ❑ _Y- <br /> 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 /> such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature <br /> employ any person in s <br /> certifies the following: certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Title: Date: <br /> Sioned <br /> FOR DEPARTMENT USE ONLY <br /> r� �� Date Area <br /> Application Accepted by % V <br /> (rr� -Final Inspection by Date <br /> ( Pit or Grout inspection by ' <br /> Additional Comments: ' <br /> F Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M <br /> I plicant Return all copies to: Environmental Health Permit/_Services 1601._E.-Hazelton_Ave., P.O. Box_2009,- Stk., CA 95201 <br /> r <br /> p <br /> :FEE AMOUNT DUE AMOUNT REMITTED CA H RECEIVED BY DATE PERMiT N0. <br /> NFO+ EH 13-24(REV.t � - ��r-EH 14-26'---a' ' <br />