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ti <br /> ' APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i ON AVE., STOCKTON, CA } <br /> Telephone 52091 456-6781 <br /> ;JPERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> (Complete iry Triplicate) ribe . This application is <br /> /or install the work <br /> n desc <br /> Application is hereby made to the San J6 quin Local Health District for sewage or permit <br /> No. 1862 forcwou/dpump and the Rules and'Regula tions of the San Joaquin <br /> made in compliance with San Joaquin G Funty Ordinance No. ; <br /> Local Health District. <br /> �� Lot'Size PM <br /> City <br /> leu <br /> Job Address <br /> Phone <br /> Address <br /> Owner's Name <br /> ' &&f�License Na. Phone <br /> dr <br /> �- L Adess <br /> - <br /> �,,,�,,,,..Contractor,�-- - WELLREPLACEMENT ❑ DESTRUCTION LJ <br /> TYPE OF WELLIPUMP: NEW WELL ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> SEWER LINES .�--- DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK _1— OTHER WELL PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL <br /> INTENDED USETYPE OF-WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS Dia,of Well.Casing_- <br /> y —"� Open Bottom�--� Q Manteca- Dia-,of-WellL -Excavation - ----= — } <br /> ••��--C� Industrial-^ ^^�" `-- Specifications t <br /> ❑ Tracy Type of Casing <br /> ❑ Domestic/Private ❑ Gravel Pack Type of Grout <br /> I ❑ Delta Depth of Grout Seal , <br /> C] Public "" f Other - <br /> Surface Seal Installed by i <br /> �{ i lrrigationv - --Appro�. Depth I l Eastern State Work bane— <br /> ' ' e Type of Ptimp H.P. •"� <br /> Repair WOrk,Done ❑ e Sealing Material atop 50'1 <br /> Well Destruction ❑ Well Diam.Ief Filler Material (Below 50'i <br /> i Depth <br /> RUCTION I 1 iNo septic system permitted if public sewer is 9 <br /> TYPE OF SEPTIG WORK: NEW INSTALLATION la REPAIR/ADDITION available within 200 feet.) . <br /> installation will serve:. R idence ommercial <br /> Other�� 1 <br /> Number of living units: Number of bedrooms + Water table depth <br /> 1 Character of soil to a depth of 3 feet: } Capacity No. Compartments <br /> -SEPTIC.TANK ❑ :Type/Mfg _ k Method of Disposal <br /> 4 PKG. TREATMENT PLT. ❑ :�- r`E Property Linea <br /> '� Well - FFoundation `J <br /> Distance to nearest: <br /> r a -� YTotal length/size <br /> C�. ength of lines <br /> LEACHING LINE r <br /> ndation 'Its_ — Property Line 1 <br /> FILTER BED ❑ Distance"to deares "'"""`WellFou <br /> ""�" `' <br /> _ Number <br /> NA <br /> SEEPAGE PITS. l I Depth# Size " r <br /> t foundation ,Property Line <br /> SUMPS f _.Distance to nearest:' 'Well"' <br /> DISPOSAL PONDS ❑ <br /> n <br /> I hereby certify that I have prepared.this application and that the work will be doneinaccordance with San Joaquin aunty ordinances,'state,laws an <br /> rules and regulations of the San Joaquin_Local Health District. work for <br /> i his H owner or licensed agent'saergin torbecome subject not <br /> following: <br /> to workman'srtcompensation lify that in the a <br /> ws Califomiahe Contractor's ng ors sub-contracting nt act is t ngls gnaterre <br /> emplo ny person in.such p persons subject to workman's compensa <br /> i certifies t following'.'3' rtify that in the part ofmance of the work for which this ermit is issued,'(stroll employ p r <br /> tion laws of Idornia.' r I <br /> lcan m t call to al equ d in actio s mp rowing on�preverse <br /> T e apPif .J�'7�1 /� Jl�_ /.✓5 > Date: <br /> Signed <br /> ` FOR DEPARTMENT' USE ONLY <br /> F <br /> V �- Date Area <br /> Application Accepted by VVV Data <br /> Final Inspection by � <br /> Pit or Grout Inspection by f41�Date Final <br /> Additional Comments: `" ❑ Tracy 835-6385 f <br /> ❑ Stk 466 6781 ❑ Lodi 369- 621 ❑ Manteca 823- f <br /> Applicant Return all copies di Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 # <br /> CK Rt:'�'IVED BY DATE PERMIT NO. ; <br /> FEE AMaUNT DUE AMOUNT REMITTED CASH <br /> INFO (0-le <br /> +.EH t3-24 1 REV.1/R5) 126 <br /> .t <br /> EH 14-26 <br />