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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE;_TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> +PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) application is <br /> '3 <br /> t to construct and/or <br /> Application is hereby made to theu n county my Ord can a No.549 for sewage oealth District for a pe r INo 1862 for well pump and the Runes and(Regulations of Thishhe San Joaquin <br /> made in compliance with San J q <br /> Local Health District. <br /> r f r � Lot Size PM <br /> City <br /> Job Addres 1 <br /> n <br /> Address <br /> .O .. f�3 <br /> Pho � <br /> t <br /> Owner's Name ,/ <br /> o - "License S*3q_3_Phone <br /> Address <br /> ContractorDESTRUCTION ❑ <br /> NEW WELL ❑ WELL REPLACEMENT ❑ W3 <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ OTHER 171PUMP INSTALLATION ❑ DISPOSAL FLD. PROP. LINE <br /> SEWER LINES <br /> DISTANCE TO NEAREST: SEPTIC TANK,-�— ti. OTHER WELL PITS/SUMPS <br /> + FOUNDATION AGRICULTURE WELL <br /> INTENDED USE e,-''TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing - <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca, -� Dia. of Well Excavation Specifications <br /> " p Tracy Type of Casing <br /> ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Grout -- <br /> r S 1 Other ❑ Deltas ;« Depth of Grout Seal <br /> I I Public Surface Seal Installed by <br /> Approi.-Depth I I Eastern <br /> I i Irrigation State Work Done_ <br /> e of Pump' —� — H.P. �° <br /> Repair Work Done ❑ TYP �.. <br /> f s `Sealing Material [top 501 <br /> Well Destruction ❑_ Well Diameter --- - Filler Materia! {Below 50') <br /> Depth a <br /> available within 200 feet.) , <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR7ADDITION I 1 'DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> ,YA <br /> 11 llation will serve: Residence— Commercial Other `s <br /> `;1.Number of living units: . Number of bedroo is Water table depth <br /> Character of soil to a depth of 3 feet: Capacity r�� No. Compartments <br /> SEPTIC TANK r Type/Mfg Method of Disposal Lr & t <br /> 1 <br /> j PKG. TREATMENT PLT. ❑ jt' Foundation/4-A—__ Property Line-- <br /> tr ' Distance to nearest: Well��.— I <br /> Total length/size <br /> LEACHING LINE - tt� 0No. & Length of lines f <br /> FILTER SED <br /> ❑ Distance to nearest: Well J <br /> Foundation /13 t.t Property Line j' n <br /> [, Size 1 umber <br /> CO <br /> } SEEPAGE PITS /`t Depth§ f 1 property Line <br /> 1 Foundation 's <br /> SUMPS L-1 Distance to nearest: Well 101) T <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that l 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.g <br /> not <br /> Home owner or licensed h manner signature certifies the <br /> become subject following: <br /> wing: "I n'srtcompensation lify that in the aws California." Contractor's hiring or sub-contracting l signshaature <br /> employ any s issued,!shall employ persons subject to <br /> certifies the following: "I certify that in the performance of the work for which this permit iworkman's compensa- <br /> folio <br /> tion laws of California." <br /> w The applicant st call or all require spect'o . Complete drawing on reverse sid C <br /> I Title: Date: <br /> • Signed X _ ti= - <br /> t FOR-DEPARTMENT USE ONLY <br /> Area 1/ > <br /> Date <br /> I } Application Accepted by <br /> Q' Date <br /> Oor Grout Inspectiony <br /> Dat Final Inspection by <br /> 31 <br /> Additional Comments: 6-6385 <br /> t ❑ Stk 466 6781 ❑ Lodi 369.3621 ❑ Manteca 623-7104 ❑ Tracy <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 3r r <br /> ACK RECEIVED BY DATE PERMIT'NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASHINFO ��C>,1��• r �,?� <br /> 4 r i 1 <br /> ♦.EH 13-24IREV.I Kb) <br /> EH 14-26 <br />