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APPLICATION FOR PERMIT <br /> SAN .fOAOUIN LOCAL HEALTH DISTRICT <br /> iJ <br /> r <br /> 1601 E. HAZEL T ON AVE.,;STOCKTON, CA <br /> ,J Telephone (209) 466-6781 <br /> OERMIT EXPIRES 51 YEAR^PROM DATE ISSUED 4;• <br /> (Complete in,Triplicate) , <br /> r <br /> �►fwork <br /> Application is hereby made to the San Co Joaquin <br /> OrdinaHealth nce No.District <br /> for sewage or. ca <br /> 1No. 1862 fort to cwellldpump,atnd the Rules and 1Regulat ontion is <br /> scribes of he San l Joaquin <br /> made in compliance with San Joaquin County a W ^ <br /> Local Health District. <br /> s , V <br /> M€ <br /> Ci Lot SPM <br /> ize <br /> lk"Job Address <br /> ` _.�:-�✓1J�lJ Phone <br /> Owner's Name <br /> Address <br /> .,'" ; rPhone <br /> License No. <br /> ,111 <br /> ddresS <br />` Contractor WELL REPLACEMENT El DESTRUCTION ❑ <br /> TYPE OF WELL NEW WELL 1-3OTHER <br /> SYSTEM REPAIR ❑ <br /> PUMP INSTALLATION ElDISPOSAL FL PROP. LINE <br /> l SEWER LINES PITS/SUMPS <br /> AGRICULTURE WELL <br /> DISTANCE TO NEAREST: SEPTIC TANK ELL - <br /> FOUNDATION �— <br /> I <br /> TYPE OF WELL PROBLEM AREA CO TION SPECIFICATIONS Dia. of Well Casing <br /> INTENDED USE —�� pia. of Well Excavation <br /> ❑ Open Bottom LD Manteca Specifications <br /> + <br /> Ll Industrial Type of Casing <br /> 1{l cy Type of Grout <br /> ❑ Domestic/Private ❑ Gravel Pack Depth of Grout Seal <br /> ❑ Other ❑ Delta <br /> EI Public ,Surface-Seal-Installed by" <br /> ❑ Irrigation prox. Depth ❑ Eastern - State Work Done_ <br /> H.P. <br /> Type of Pump <br /> Repair Work Done 6 <br /> Sealing Material Itop 50'1 <br /> i Well Destr - n ❑ Well Diameter Filler Material (Below 50') <br /> 1 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADD�TION ❑ DESTRUCTION (No <br /> lvailabpe1wthin 200 feet;) if public sewer is <br /> Commercial Other., t: ; <br /> Installation will serve: Residence �» ` f' <br /> i Number of living units: Number of bedrooms Water table depth 5 <br /> j Character of soil to a depth of 3 feet:- " No. Compartments <br /> Capacity— <br /> SEPTIC TANK ❑i Type/Mfg. Method of Disposal ' <br /> r <br /> PKG. TREATMENT PLT. ❑1 Foundation Property Line <br /> I Distance to nearest: Well <br /> ❑ No. & Length of lines c Total length/size <br /> l LEACHING LINE P' -'� `��� Property Line <br /> FILTER BED Ll Distance to nearest: Well Foundation p <br /> I. <br /> Size Number <br /> SEEPAGE PITS ❑ Depth _.Foundation Property line <br /> SUMPS .-L]�..Distance.to.nearest:,.... -Well <br /> DISPOSAL PONDS ❑I <br /> � rid that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application a <br /> rules and regulations of the San Joaquin Local Health District. y that in rtifies the g <br /> Home owner er lil not <br /> c m such mannerasloth some subiectt to workman'srcompensation lawsoof California." Contractor which <br /> hiring osub-contracting lsignlature <br /> employ any p erspns 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 p 1 <br /> tion laws of California." . }-" , , J # <br /> The applicant ust or uired i pe tions. Complete dr ing o ev se side. _ <br /> Title: Date: <br /> Signed X i, <br /> p�4RT NT USE ONLY �--3 <br /> •. <br /> - Date Area <br /> Application Accepted by ,, <br /> Pit or Grout Inspection by Date <br /> Final Inspection by Date�36-, <br /> Additional Comments: <br /> i ❑ Stk aS6-6781 ❑ Lodi -369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Environmental lth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009; Stk., CA 95201 <br /> Applicant - Return all copies to: Hea <br /> c CK RECEIVED 6Y DATE i PERMIT NO. <br /> ( FEE <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> °+ EH 13-241REV.%/Hb1 � - <br /> EH 14-28 <br />