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+t - Y +fir.� ' •r ,"s`.+ t F�"� .F - ;_n,. - „% M'vn.--e �_. - <br /> s APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.,HAZElTON AVE:;-STOCKTON, CA <br /> Telephone(208) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r <br /> y, (Complete in Triplicate) <br /> describ , This <br /> is <br /> Application is hereby made to the SanU1 nalNo.Health 548 istrict for sewa for a pe or INo. 1862 foto r well pump and the Rules and hereint and/or install the work R gulations of he Sanl cation Joaquin <br /> made in compliance withCoun San Joaquin tyOrdinancence r - "� <br /> Local Health District. <br /> I <br /> City_ -' Lot Size PM <br /> Job Address <br /> of Phone <br /> gg <br /> Owner's Name <br /> �O 1 <br /> Address r+e`a� <br /> Add �D Z <br /> 1 S License No. Z123 <br /> Phone Z P <br /> Contractor's Name <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> SYSTEM REPAIR ❑ OTHER LJ <br /> PUMP INSTALLATION 17� ;� � ;-- SEWER LINES -�� DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial; ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> i-, Specifications <br /> ❑ Domestic/hPrivate ❑'Gravel`Pao. -� Tracy Type of Casing_ =f _ . s . . <br /> Delta —Dept <br /> h of Grout.Seal- r _ Type of Grout <br /> ❑ P blicu ... �_ -�-,. EI-Other--, -n <br /> Irrigation ' �pprox. Dep h ,�❑ Eastern Surface Seal Installed by C �+ <br /> / State Work Done <br /> Repair Work Done Q' Type of Pump w +� H. — <br /> Well Destruction CD Well Diameter Sealing Mater al�itop 50 —= <br /> Depth r; <br /> ­- Filler,Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑t REPAIR/ADDITION ❑ DESTRUCTION C1 (No <br /> avasepticlable within 200 emitted if public sewer is <br /> 1'�� J <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number f bedrooms Water table depth <br /> Character of soil to a depth of 3 feet. No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> d <br /> Distance to nearest: W <br /> Foundation Property Line <br /> : <br /> Total length/size <br /> LEACHING LINE ❑ No. & L•ength of lin Property Line <br /> FILTER BED ❑ Distance to nea t: Well ndation <br /> SEEPAGE PITS ❑ Depth <br /> Size Number <br /> SUMPS L1Distance,to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 3 <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 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 /> employ any person i manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the folio ng:"I c rfY that in the performance f the work for which this permit is issued,1 shall employ persons subject to workman's compensa <br /> tion laws of ifornia." <br /> The applic t u ca all requir i /awing on rev e. -1 ;6(40 —4 <br /> Signed <br /> Title: .1 Date: <br /> FOR DEPARTMENT USE ONLY /,, 1 <br /> Date �' - Area 1 <br /> Application Accepted by <br /> Date Final Inspection by-5 , Date <br /> Pit or Grout Inspection by J h <br /> Additional Comments. <br /> ❑ Stk 4664781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 O Tracy 635-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2DD9, Stk., CA 95201 <br /> FEE CK RECEIVED By DATE PERMIfNO.' (4� <br /> AMOUNT DUE AMOUNT REMITTED CASHINFO i •rte <br /> rLi MN00 <br /> + EH 13-24 IREV.10/031 <br /> ' EH 1426 - <br />