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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> s 1601 E. HAZETON AVE., STOCKTON, CA <br /> a. Telephone(209) 466-6781 <br /> ri <br /> / PERMIT EXPIRES 1 YEAR`FROM DATE ISSUED , <br /> (Complete in Triplicate) ., <br /> ll the work <br /> rein <br /> Application cation is <br /> is hereby made to the San Joaquin di orHealth dinance No.0549 for sewage or permit <br /> No. 1862 for well pump and the Rules amend Regulations of�ibed.This aPPIr�quin <br /> made in compliance with San Joaquin Coity f <br /> Local Health District. r. <br /> �] ''"r City i Lot Size <br /> PM <br /> lopJob Address <br /> f _ Phone <br /> f Address <br /> Owner's Name s i <br /> I License No/0 <br /> 0 Phone <br /> Contractor rens <br /> NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR El <br /> ❑ <br /> PUMP INSTALLATION ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TAMC i .X OTHER WELL PITS/SUMPS <br /> FOUNDATION �— AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL s PROBLEM AREA CONSTRUCTION SPECIFICATIONS .Dia. of Well Casing - <br /> ❑ Open Bottom 0 Manteca Dia. of Well Excavation <br /> 0 Industrial 1 ❑ Tracy Type of Casing —Specifications <br /> ❑ Doffiestict Private ❑ Gravel Pack t Type of Grout s <br /> ❑ Public <br /> ❑ Other `t ❑ Delta Depth of Grout Seal; <br /> ❑ Irrigation <br /> _--Approx. Depth ❑ Eastern Surface Seal Installed by <br /> H P I State Work Done <br /> Repair Work Done ❑ Type of Pump �� <br /> -- Sealing Material.40P-50' <br /> Well Destruction ❑ Well Di-1 1 eters—� Filler Material Iselo <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION DESTRUCTION Nail bleiwthinem pernii200 feet.) 1f public sewer isJC <br /> - f �. <br /> F Other <br /> installation will serve:-,Resi enc" Commercial J <br /> ' Number of bedrooms b <br /> Number-of living units: Water table depth <br /> Character of soil to a depths of 3 feet: Capacity No. Compartments <br /> SEPTIC TANK ❑ 'IType/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ 1 �°""� " <br /> ndatian Property Line <br /> Distance to neart�—Well i r <br /> 101111 11 011111111 <br /> Total length/size <br /> LEACHING LINE No.�& Length of lines Property Line <br /> FILTER BED Q Distance to-nearest: Well! ' Foundation / <br /> SEEPAGE PITS ❑ Depth-- izeu <br /> Number <br /> Property Line <br /> UMP El .Distance to nearest: Well- Foundation �{ <br /> ISPOSAL PONDS ❑ <br /> �--: <br /> I hereby certify•t6t.I have prepared this api lication(arid that the work will be done in accordance with:San Joaquin county ordinances, state laws,an <br /> rules and regulations of the San Joaqu'ii1 Local'•Hea7th District. ss <br /> Homo owner erslone nssuch mannorgas to become subject Ito workman's compensation Ing: "I certify that in the awsoof Califormance rnia„"Contractor's Ih ring or sub-const act ng signature <br /> 4 <br /> employ Y P <br /> ! certifies the following:"t certify that In thH performance of the work for which this permit is issued,I shall employ persons subject to workman s compensa- <br /> tion laws of California." <br /> { The applican <br /> for all r it E inspections. Comp) drawing o re rse'side: _ *�... <br /> ..- - Title:_ 'Date: <br /> Signed �. <br /> s .� 'Q FOR DEPARTMENT USE ONLY 1 <br /> f-. 1 p� <br /> Date a��`t' "" Area�1 <br /> Applic ri Accepted by c�Q! � <br /> �U �J Final Inspection by <br /> Date <br /> Pit ,.Date o = .� t7 t3 <br /> Additional Comments:_ � <br /> Tracy 835-q85 � ,. <br /> ❑ Stk 466-6781 0 L 1 369-3621 ❑ Ma 823-7104 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> ' FEE AMOUNT REMITTED CK RECEIVED 8Y- �` DATE PERMIT'NO. <br /> INFO AMOUNT DUE CASH <br /> + EH 13-24(REV.1/8 51 <br /> EH W26 - <br />