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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL'HEALTH DISTRICT <br /> 1601 E. HAZELTON.AVE., STOCKTON, CA { <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1,YEAR FROM DATE ISSUED � <br /> (Complete in Triplicate) i,t: . <br /> to construct <br /> .This aPPIlbation is <br /> Application is hereby made to the SanJoaquin Ord na He lth D549 for sewage or Iand/or I <br /> No. 1862 for well/pumP and the Rules and Regulations of theSan Joaquin <br /> Co <br /> made in compliance with San Joaquin County i <br /> Local Health District.. ! f ° <br /> �. <br /> City S=w A'o Lot Size PM .-. <br /> Job Address a d, <br /> Phone -� <br /> Y- • Address _ ����-' <br /> Owner's Namle <br /> Phone <br />' r license NO. <br /> Contractor`s Name A4WELL REPLgCEMENT <br /> WELL <br /> SYSTEM REPAIRQ DESTRUCTION 7-1NEW <br /> TYPE OF WELL/PUMP: , OTHER❑' <br /> PUMP INSTALLATION' I' <br /> SEWER LINES �.—.— DISPOSAL FLD. PROP. LINE <br /> �— <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL. � <br /> - <br /> k T TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE a pia. of Well Casing <br /> Dia. of Well Excavation— <br /> 1 ❑ Industrial ❑ Open Bottom Q Manteca 1 .1" 1 Specifications <br /> Type of Casing, <br /> k?Domestic/Private ❑ Gravel Pack ❑ Tracy " Depth of Grout Seal Type of Grout <br /> El Other <br /> El Delta <br /> [I Public Surface Seal Installed by <br /> ❑ Irrigation �4Pprox. Depth El Eastern <br /> H P �[J$i` — state Work Done t <br /> Repair Work Done ❑ Type of Pump -of Sealing Material (top 50'1 <br /> Well Destruction ❑ Well Diameter Fillet Material (Below-50'1 <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION D DESTRUCTION ❑ alvail available <br /> within 200 feet.) if public sewer is <br /> installation will serve: Residence.— Commercial— Other�— <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: Capacity— Nod Compartments' <br /> SEPTIC TANK ❑ Type/Mfg <br /> Method of Disposal <br /> 'PKG. TREATMENT PLT. ❑ <br /> Well �-- <br /> Foundation Property Line <br /> Distance to nearest: �-�-- <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well <br /> Foundation Property Line--•� <br /> Size Number . <br /> SEEPAGE PITS ❑ Depth <br /> SUMPS Property tine <br /> ❑ Distance to nearest: Well Foundation -- <br /> —DISPOSAL-PONDS ❑ — <br /> I herebycertify 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.g. work for <br /> shall not <br /> Home owner or licensed agent's <br /> gm is sig s to become subjectf following: <br /> wing: "I certify <br /> nrs comp <br /> ensation in the <br /> IS soot California.e Cont actor s1hir ng or sub-contracting this permit is issued, lsignature <br /> employ any person in such <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 compen -. <br /> tion laws of Caliiforni i <br /> The applicant must all r it spections. Complete drawing on rever"e. 4 <br /> // [ ,7��` Date: ) t, <br /> Title: — , <br /> Signed •,_P«Vin` �. <br /> FOR ARTMENT USE ONLY . <br /> Date Areta ^''ry !'"" P• <br /> Application Accepted b t: Data` r <br /> ate �— Final Inspection by <br /> 'Pit or Grout Inspection y ¢/ +`';r71 <br /> Additional Comments: El 623 7104 , ❑'Tracy '635-6385 <br /> ❑ Stk 466 6781 ❑ Lodi 369-3621tk., CA 95201 <br /> .'tN., '..,a 3 <br /> Applicant- Return all copies to: Environmental Health Permit/Sefvices 1601 E. Hazelton Ave., P.O.POBox 2009, 5 rt, <br /> CK RECEIVED BY DATE. PERMIT`„96H ` <br /> FEE 7 AMOUNT DUE AMOUNT REMITTED CASH ...�--• <br /> '�'`� � �Ig �1 <br /> +EH 1324(REV.10193) INFO 2? S OD - f _ <br /> EH 14.28 <br />