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APPLICATION FOR PERMIT Via. <br /> =` " 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 /> (Complete in Triplicate) <br /> in /or install the <br /> rk <br /> , This <br /> cation is <br /> Application is hewith a to the <br /> aqu n County ordinance llNto.549 for sewage h-District for a or 1Nv. 1862 fort to cwe111dpump and the Ruoles and(Regulations of the 5anl Joaquin <br /> made in compliance , <br /> Local Health District. <br /> City Lot Size PM <br /> Job Address <br /> Address Phone / t <br /> .t, � `-D <br /> Owner's Name <br /> License No. Phone <br /> Contractor Address <br /> WELL REPLACEMENT ❑ DESTRUCTION 11TYPE OF WELL/PU NEW WELL ❑. 1 P C <br /> PUMP INSTALLATION Cl SYSTEM REPAIR'© � ' •. OTH ° <br />' SEWER LINES .. AL FLO. _PRO.P_.IIIVE <br /> DISTANCE TO NEAREST:-SEPTIC TA OTHER WELL PITS/SUMPS <br /> I <br /> FOUNDATION ELL <br /> INTENDED USE TYPE OF WELL EM AREA CONS ON SPECIFICATIONS <br /> Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bot ❑ Manteca Dia. of Ca Excavatio `4�1 <br /> Type of Casing Specifications <br /> ❑-Domestic/Private — ❑ e Pack ❑ Tracy yp g e�ti out - <br /> M Public Other F-Delta Depth o1 Grout Seal <br /> I ! Irrigation ` ---Apprnz.-Depth I-I Eastern —Surface Seal Installed by <br /> State Work Done <br /> Repa' ark Done ❑ Type of Pump <br /> H P " 1 <br /> Well D struction [J Well Diameter Sealing Material Stop 50'I <br /> Depth Filler Material lBelow 50`1 <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION lri DESTRUCTION (No septi systemithin permitted if public sewer is <br /> available Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: "''f_ J Water table depth <br /> # SEPTIC TANK El Type/Mfg <br /> Capacity No. Compartments <br /> "* <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ .. <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size 1 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> M ' Number <br /> SEEPAGE PITS l I Depth Size <br /> SUMPS L� Distance to nearest: WellFoundation Property Line <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 Yaws, and <br /> i rules and regulations of the.San Joaquin Local Health District. <br /> t 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, I shall tial <br /> na <br /> employ any person in such manner as to become subject to workman's compensation laws,of California." Contracecsonslsub ct to workman''scompensa- <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ p 1 <br /> tion laws of California." <br /> The applica ust c for all quired ' spections. Complet drawingo .reverse side. <br /> I <br /> Title: Dat <br /> ..Signed Xe: <br /> FOR DEPARTMENT USE ONLY F <br /> i Date Area <br /> Application Accepted by <br /> ate <br /> Pit or Grout Inspection by D to Final Inspection by , <br /> Additional Comments: <br /> ID Stk 466-6781 L1 Lodi 369-3621 CI Manteca 823 7104 ❑ 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 /> 4 ^ <br /> EINFO <br /> AMOUNT DUE ;AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> ♦ EH 13-24{REV.t/K 5) _ <br /> EH 14-26 <br />