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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL-TON AVE., STOCKTON, CA _. <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r <br /> " <br /> b s:�4r(Complete in Triplicate) � _ ';1 <br /> - i�. <br /> all <br /> the <br /> .This <br /> /or inst <br /> Application is hereby made to the San Coun uI Ordinance alto District sewage or permit <br /> 1862 for wellldpump and the Rules and Regulations of the Sant Joaquin <br /> made in compliance with'San Joaqui tY <br /> Local Health District. X:,, M <br /> 4 �- <br /> City <br /> Lot Size <br /> Job Address - _,� D <br /> ss <br /> �1 ' �; -.•-- -. � Phone <br /> Addre ' <br /> 71 <br /> Owner's Name ILA <br /> F License No. <br /> Contractor's Name WELL REPLACEMENT © DESTRUCTION ❑ <br /> TYPE OF WELL/PUM NEW WELL ❑ OTHER ❑ <br /> = SYSTEM REPAIR ❑ <br /> '- PUMP'WSTALLATION ❑ <br /> DISPOSAL FLD" PROP. LINE <br /> E `SEWER LINES �� PITS/SUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK _ AGRICULTURE•WELL OTHER WELL <br /> N t I FOUNDATION. <br /> L INTENDED USE TYPE OF WELL PROBLEM AREA/CONSTRUCTION SPECIFICATIONS Dia. of Weil Casing <br /> k pia. of Well Excavation <br /> ❑ Industrial ❑ Open°Boitem ❑ Mantec Specifications <br /> ❑ Tracy Type of Casing <br /> ❑ Domestic/Private `N ❑ Gravel Pack Y Type of Grout <br /> ❑ Other ❑ Delta Depth of Grout Seal ' <br /> [3 Public Surface Seal Installed by <br /> i <br /> ❑ Irrigation r��pprox. Depth [3 Eastern State Work Done <br /> Repair Work Done ❑ Type;of Pump H P' � <br /> Sealing Material (top ) , 1 <br /> l Well Destruction ❑ Well Diameter e5-Material ( el 50'), <br /> ' Depth <br /> _ available within 200 feet.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION.❑ EPAI DDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> Installation will serve: Residence Commerci Iher.,�1 <br /> Number of bedroo s Water table depth <br /> k <br /> Number of living units: A. <br /> Character of soil to a depth of 3 feet: f �� ,C.111 apacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg t x �4 Method of isp <br /> PKG. TREATMENT PLT. ElProperty Line <br /> I Distance to nearest: Weir 0 0 Foundation•�/ <br /> Tota! length/size <br /> LEACHING LINE [I No. & Length of lines '� (� property Line <br /> FILTER BED ro-1, Foundation° '9 <br /> ❑ Distance to nearest:. Well ` <br /> i � f <br /> Size Number d <br /> i SEEPAGE PITS ❑ Depth Pro tine ` <br /> ❑ 'Distance to nearest: Well I Property Foundation <br /> SUMPS - - <br /> DISPOSAL PONDS ❑ <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 /> that in the l not <br /> Home owner or licensed agent's signature <br /> gas tobecomesubject Ito workman's lowing: "I rt compensation lawsoof California."Contractor's r 1hiring or sub-contracting Signthis permit is issued, I lature <br /> employ any person in such mann arsons subject to workman's cornpensa- <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,l shall employ p <br /> 1 tion laws of California." <br /> The applicant u r e u!5- coons. Cjornp , drawing on reverse side. <br /> Date: <br /> ! Title: <br /> 4 Signed <br /> 6 FOR DEPARTMENT USE ONLY <br /> Date Area <br /> ` Area <br /> Application Accepted by Data <br /> � - Date Final Inspection by <br /> _ Pit or Grout Inspection by ..". <br /> Additional Comments: ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> I ❑ Stk 466-6781 ❑ Lodi 369-3621 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2+?09, Stk.; CA'95201 <br /> CK RECEIVED 8Y D TE <br /> PERMIT`ND. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> )NFO <br /> + EH 13.24(REV.10183) <br /> EH 14-26 <br />