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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE.,-STOCKTON, CA <br /> 'Telephone (209) 466-6781 .f <br /> PERMIT EXPIRES~1 YEAR FROM DATE.ISSUED t <br /> .,.(Complete in Triplicat0r '° ' <br /> Application is+hereby made to the San Councation is <br /> ty Ordnance No.District549 for sewage or permit to <br /> 1862 for construct and/or <br /> and the Rules and 1Regulations of he Sang Joaquin <br /> made in compliance with San Joaquin -p <br /> Local Health District. <br /> Size <br /> City �d�Kt PM <br /> Job Address (� <br /> p Phone r Z L <br /> MA <br /> Address' <br /> Owner's Name J S <br /> License-No-- Phone <br /> Contractors Address <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LJ DES TRUCON ❑ <br /> T <br /> k PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR 11 OTHER 1-1 <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITSISUMPS �. <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> . Dia. of Well Excavation <br /> ❑ Industrial El Open Bottom ❑ Manteca Specifications <br /> -� ❑ Tracy Type of Casing <br /> ❑ Domestic/Private ❑ Graved Pack Depth of Grout Seal Type of Grout <br /> I <br /> L] Public " ❑ Other ` ❑ Delta <br /> ❑ Irrigation ---Approx. Depth .. ❑ Eastern <br /> Surface Seal Installed by <br /> ( Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> ISealing Material {top 50'1 <br /> Well Destruction ❑ Well Diameter Filler.Material (Below 50'1 1- <br /> Depth <br /> ` TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION available septic sy t 200 rmiittted if public sewer is <br /> "±Commercial Other <br /> j Installation will serve:i;,,Residence�� e ry t <br /> } <br /> Number of living units: Numberof bedrooms ., y.y g."R�a �� _ I Water table depth <br /> l Character of soil to a depth of 3 feet: . ` <br /> SEPTIC TANK El Type/Mfg <br /> ----�' 1 0 Capacity No. Compartments <br /> f,e} Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> i Distance to nearest: Wel Property Foundation °'t— Line <br /> i <br /> Total length/size 4 <br /> r LEACHING LINE ❑ No. & Length of lines �.� Y <br /> FILTER BED LJ Distance to nearest: Well <br /> Foundation Property Line ' <br /> Size Number ` <br /> SEEPAGE PITS El Depth <br /> Property tine <br /> SUMPS ❑,, Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ <br /> hereby certify that 1 have prepared this application and that the work will'be done}n accordance witti San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. for <br /> Home owner or licensed agent's signature certiffe sub eco Ito wo :."I,c srtcom-that <br /> -in <br /> the <br /> ion Iw soof Califarniahe Conkract r'slhiringl orp suh cont act ngl signature <br /> employ any person in such manner as to becom 1 'sh subject to workman's compensa <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued, i shall employ persons <br /> i tion laws of California." <br /> The appli ant must call for all r quir inspections. Complete drawing on reverse side. �6 __o� <br /> Title: Date. <br /> Signed <br /> FOR,DEPARTMENT USE ONLY <br /> 44 <br /> r <br /> Date 'fp�// Area <br /> Application Accepted by <br /> Final Inspection by Dat <br /> Pit or Grout Inspection by Date , <br /> r <br /> Additional Comm( A <br /> ❑ Stk 466-6781 �, a�i,�,69-3621 ❑ Manteca 823-7104 ❑ Tracy 83x6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009. 5tk., CA 95201 <br /> K RECEIVED BY DATE PERMIT'NO. <br /> FEE AMOUNT DUE' AMOUNT REMITTED �C <br /> INFO oo �35 .a0 17 112, ��" <br /> r EH 1324(REV.5 <br /> EH 1428 <br />