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. <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH `DISTRICT E5 <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA R �� <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> j permit <br /> - application is <br /> Application is hei wmaith e to the San Courgity Otd'inalnce No. 549 for sewage or INo. 1862 for cwe Ildpump and the Rules and/or install the work (Regulations of the San Joaquin <br /> made in compliance <br /> Local Health District. <br /> V � � o f City of Size PM <br /> Job Address ���� `�� +�► r— <br /> r / ,6.r— 15 Phone <br /> Owner's Name N i1 <br /> Contractor Address <br /> License No._ Phone <br /> !PUMP: NEW WELL CJ WELL REPLACEMENT [-I DESTRUCTION ❑ <br /> TYPO <br /> F WELL _ OTHER ❑ <br /> E <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L7 �� <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> FOUNDATION <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia of Well Casing <br /> L-1 Industrial ~— n Open Bottom <br /> Ll Manteca <br /> Dia. of Well Excavation Specifications <br /> t ❑ Trac Type of Casing <br /> ❑ Domestic/Private F1 Gravel Pack y Type of Grout ------ <br /> 17 Other l-1 Delta Depth of Grout Seal <br /> F! Public --- <br /> �.__.Approx. Depth t I Eastern Surface Soni Installed by <br /> I Irrigationr State Work Pone — <br /> Repair Work Done ❑ Type of Pump H.P. <br /> Well Destruction . ❑ Well Diameter r Sealing Material (top 501 __ <br /> Depth— I Fillet Material ISelow 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 <br /> REPAIR/ADDITION l 1 DESTRUCTION (No ilabpelwithin 200 feetstem per t�ed if public sewer is <br /> Installation will serve: Residence ' Commercial_ Other <br /> t <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK n Type/Mfg � � Capacity.__ <br /> Method of Disposal <br /> i PKG. TREATMENT PLT. ❑ Property.Line <br /> l Distance to nearest: Wel! Foundation <br /> ;f <br /> LEACHING LINE f_l Na. &`�engih of lines <br /> _ Total length/size--i <br /> FILTER BED <br /> ❑ Distance to nearest: Well Foundation Property Line <br /> l I Depth�� Size -- _--- Number <br /> SEEPAGE PITS - <br /> ` Property Line <br /> SUMPS LI Distance to nearest: Well Foundation__—�� <br /> DISPOSAL PONDS [-f <br /> this application and that the work will be done in ac <br /> ! hereby certify that l have preparedcordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health a following: <br /> District. <br /> Home owner or licensed agent's signature certifies the following: '"f certify that in the performance of the work for which this permit is is-contsubsued, 1 signature <br /> shall not <br /> I employ any person in such manner as to become subject to workman's compensation laws of California." Contractef's hirigorto workman's9ompensa- <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, i shall employ psubject <br /> i <br /> tion laws of Califo <br /> The applicant ust c I for all7 r� fired nspections. Complete drawing on reverse side. <br /> f Signed 7( <br /> Title: Date: <br /> fx` � FOR DEPARTMENT U5>: ONLY(� Date2 Area <br /> Application Accepted by <br /> Pit or Grout inspection y <br /> Date Final Inspection by Date <br /> Additional Comments: V <br /> ❑ Stk 466-6781 ❑ Lodi 3 3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> lth Permit/Services 1601 E. Hazolton Ave., P.O. Box 2009, Stk., CA 95201 <br /> Applicant - Return all copies to: Environmental Hea <br /> FEEC RECEIVED BY DATE PERM11'N0. <br /> INFO <br /> AMOUNT DUE AMOUNT REMITTED �f1 <br /> . EH 1324 IREV.1/"5) <br /> EH 14-26 <br /> tC <br />