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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> /or install the work <br /> n described. This <br /> cation is <br /> made inti <br /> lcompliance writh San Joaquin County O d nalnce Nto.549 for sewage or permit <br /> 1862 for cwe111dpump and the Rules and IRegulationss of the San l Joaquin <br /> Local Health District. <br /> F <br /> • City tot Size rT PM <br /> Joh Address � �- <br /> (' { I <br /> Owner's Name ^ J—_ 'I Ad ress,l `/' - '� Phone <br /> �—ss ..r-,..,,_, License No.<r'"" 7 Phone tF <br /> ! <br /> Contractor� <Address _ <br /> NEW,WELL 11WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: <br /> PUMP'INSTALLATION ❑ <br /> SYSTEM REPAIR F1OTHER D <br /> DISPOSAL FLD. PROP. LINE <br /> y` <br /> DISTANCE TO NEAREST: SEPTIC TANK• SEWER LINES <br /> I FOUNDATION- AGRICULTURE WELL OTHER WELL PITS/SUMPS (`n� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing,{ <br /> E3 Industrial ❑ Open Bottom © Manteca Pia. of Well Excavation t <br /> --Type of Casing Specifications j <br /> ❑ Domestic/Private ❑ Gravel Pack D Tracy yP g Type of Grout' — <br /> ❑ Other (-1 Delta Depth of Grout Seal <br /> l`l Public <br /> I 1 IrFigation —._Apprax. Depth fill Eastern t- Sud ace Seal installed by <br /> Repair Work Done ❑ Type-of-Pump r <br /> H State Work Done <br /> WeII'Destruction [3 Well Diameter Sealing Material flop 50'1 <br /> Depth .A ,4Piller Material (Below 501 . <br /> TYPE OF SEPTIC'WOLATION I. REPAIR/ADDITION i.i DESTRUCTION t I (No septic system permitted it public sewer <br /> RK: NEW INSTALis <br /> ' <br /> available within 200 feet.i <br /> A <br /> Installation will serve "Residence= 't omme`rcial"" '��Othe'r""µms <br /> Number of living units: Number of bedrooms <br /> r + Water table depth <br /> f Character of soil to a depth of 3 feet, <br /> fie/hAf m Capacity ' No. Compartments <br /> SEPTIC TANK ❑ TYP 9 Method of Qispo I I <br /> PKG.-TREATMENT PLT. Q <br /> t Distance to nearest: ' Well f Foundation Property Line <br /> Total length/size <br /> LEACHING LINE 0 Na. & Length of lines <br /> i <br /> Line i <br /> FILTER BED D Distance Nto nearest: Well fl�f� Foundation C} Property <br /> e Number i <br /> SEEPAGE PITS l 1 Depth Size <br /> SUMPS L� Distance nearest: Well ,[�L — Foundation — Property Line <br /> l DISPOSAL PONDS ❑ w <br /> I <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stale laws, an <br /> 1 rules and regulationsof the.San Joaquin Local Health District. 1;, - <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 in such mariner as to become subject to workman's compensation laws of Californcontractor's hiring or sub-contracting signature <br /> ia." <br /> 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 /> lionilaws of California." <br /> The applicant must call for all required inspecti6ns�Gomplate drawing on reverse s do. <br /> 1 ` Title: • ..Data / 1 <br /> Signed X ; <br /> FOR DEPARTMENT USE ONLY <br /> 1Date w Area <br /> Appiieauon Accepted by. <br /> fi <br /> CP <br /> r Grout Inspection by Do <br /> Final Inspection b Dat ��2 <br /> Additional Comments: 1 <br /> j ❑ Stk 466-6781 ❑ Lodi 369 3621 D Manteca 823-7104 E. <br /> Tracy 835-6385, P.O.Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P. Box 2009, Stk., GA 35201 <br /> FEE CK RECEIVED BY DATE "PERMITINFO AMOUNT DUE AMOUNT REMITTED CASH <br /> — _�EH 13-21 IF EV.V/x5) :.. , ' le <br /> EH 14-28 <br />