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1 APPLICATION FOR PERMIT <br /> SAN JOAQUIN"LOCAL HEALTH DISTRICT <br /> i 1601 E. HAZE.T ON AVE., STOCKTON, CA <br /> I� Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1 (Complete in Triplicate) <br /> p hcation is <br /> I Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This app <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for weVpump and the Rules and Regulations of the San Joaquin <br /> 1 co a1 Health District. <br /> ii011 �„ S� City Lot Size PM <br /> Job Address <br /> i �i3 /u 15'J.-725 Address phone <br /> Owner's Name _ � t ' <br /> f !! '� Address �c z ��'� License No.A2. s -Phone <br /> 4 <br /> + Contractor' <br /> TYPE OF WELL/PUMP: NEW WELL 173 WELL REPLACEMENT C1 DESTRUCTION LI <br /> I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> iDISPOSAL FLD. PROP. LINE <br /> �4 <br /> INSTANCE„TO NEAREST: SEPTIC TANK SEWER LINES <br /> Y ; FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> " INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industria! L1. Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> t J' Type of Casing Specifications <br /> ❑`Domestic/Private: ❑`Gravel Pack ❑ Tracy Type of Grout <br /> rl;Public C1 Other t f] Delta Depth of Grout Seal <br /> I 1 Irrigation t_Approx. Depth I 1 Eastern Surface Sea! Installed by <br /> Repair Work Done ElType of Pump H.P. State Work Done _ Q) <br /> Well Destruction ❑ well lNDiameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 stem C� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIRIAODITION l.1 DESTRUCTION (Noavas septic <br /> within 200 teetlued it public sewer is <br /> installation will serve: Residence�-- Commercial Other <br /> # Number of living units: _ Number of bedrooms. <br /> s .-- - •- Water table depth <br /> Character of soil to a depth of 3 feet; J <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ - <br /> Method of Disposal i <br /> Property LineFoundationDistance to nearest: Well <br /> r <br /> LEACHING LINE 4-.0 No. & Length of lines Total leng <br /> .x th/size <br /> ,. i x. r'. . <br /> FILTER BED LJ Distance.to nearest: Well Foundation �. Property Line <br /> � <br /> - -Number__ <br /> .,SF:EPAGE PITS. ,I�I�DepthSize <br /> • _ � � <br /> ! SUMPS I L3 Distance to nearest: Well Foundation—Propertai Line <br /> 1.' <br /> } pISPOSAL PONDS ❑` <br /> s <br /> 'I h.areby certify that I have prepared this application and that the work will I bdone in accordance with Sand Joaquin county ordinances, state laws, an <br /> rules and regulations of the San Joaquin Local Health District. tq' <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 shalt not <br /> I <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 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 /> i tic'n laws of California." <br /> 1 The applicant must call far II required inspections. Complete drawing on reverse side. } <br /> ' Signed X--" Title:_ Date: <br /> i! c FOR DEPARTMENT USE ONLY <br /> Application Accepted by w" ` ` Date Area <br /> ' Dat�P ' <br /> Pit or Grout Inspection by Date Final Inspection by <br /> -N <br /> Additional Comments: 04 <br /> •� Q-Stk-:r.�466-6781.,,.-..--Cl.Lodi—3&3621—. LI —-LI Manteca ......0,T.racy-835-6385 <br /> Applicant Return all copies to: Environmental Health Permit/services 1801 E Hazelton Ave., P.O.,Box 2009, Stk., CA 95201 t>� <br /> i IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY D�ATTE^(� PERMIT"NO. <br /> + Eli t3-24(REV.i 1 a sl <br /> EH 74-28 <br />