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" APPLICATION FOR PERMIT <br /> I t f SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> tct <br /> {Complete in Triplicate} application. This is <br /> /or install the work <br /> Application is hereby made to the u n county DLoca H N°.ealt 549 for sewage or permit <br /> No. 1862 for wel!ldpump and the Rules and herein <br /> Regulations of the San Joaquin <br /> made in compliance with San Joaq <br /> Local Health Districu <br /> zs w� at Size PM .—�-- <br /> -r f,� City <br /> Job Address; <br /> Phone <br /> Address <br /> Owner's Name _ rD <br /> ense No. Phone <br /> ress <br /> Contractor WELL REPLACEMENT ❑ DESTRUCTION 13TYPE OF WELL/PU P "EW W LL ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> ' SEWER LINES __—— DISPOSAL FLD. "'' PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK 'OTHER WELL P1TSISUMPS <br /> FOUNDATION AGRICULTURE WELL <br /> k <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing { ,❑ Open Bottom ❑ Manteca Dia. of Well Excavation vv <br /> ❑ Industrial Type of Casing Specifications — <br /> l ❑ Oomestic/Private ❑ Gravel Pack L1Tracy Type of Grout <br /> Ll Other M Delta Depth of Grout Seal <br /> 11 Public „ . t.. <br /> Approx. Depth I I Eastern Surface Seal Installed by r <br /> I i litigation ;, H.P. f State Work Done <br /> Repair Work Done U Type of Pump ��-� <br /> Q <br /> Seling Material (top <br /> Well Destruction Well Diameter <br /> Depth Filler Material lBelo 50`1 <br /> available within 200 feet.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l l - REPAlRlADDITION l (No septi <br /> DESTRUCTION l 1 septic system per <br /> if public sewer is <br /> installation will serve: Residence Commercial Other <br /> Number of living units: Number of bedrooms Water table depth <br /> i _ <br /> + Character of soil to a depth of 3 feet: _ [Capacity- <br /> No..'compartments <br /> I SEPTIC TANK r., ❑ Type/Mfg Method of Disposal <br /> IIII PKG. TREATMENT PLT. ❑ s Pro a Line <br /> Distance to nearest: Well Foundation p <br /> i Total length/size <br /> �E, CHING LI ❑ No. & Length of lines pro ert Line <br /> ER BED <br /> ❑ Distance to nearest: Well Foundation p y <br /> � f! tfQ � <br /> i SEEPAGE PITS I'1 Depth ;.� _ Size <br /> �? mbar <br /> l Foundation Property Line <br /> SUMPS ❑ Distane to nearest: Well <br /> i DISPOSAL PONDS ❑ ` <br /> G I hereby certify that l have prepared this application and that She 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 /> shalt not <br /> Home owner or licensed <br /> in such mannera;signature <br /> become subjects to wlorkman'srtcompensat on lthat in the aws°of California." Contractor's lhit ng'or sub-cont actingermit is issued, lsignaturre <br /> employ any pe pe p persons subject to workmans compensa- <br /> � certifies the following: "!certify that in the performance of the work for which this permit is issued,l shall employ <br /> tion laws of California." <br /> applicant st c I f 11 requil d ins ctions. Com awing an r . era side. <br /> The app Date: - <br /> I Title: <br /> Signed X <br /> FOR DEPARTMENT USE ONLY J <br /> i Date <br /> r Area <br /> } Application Accepted by <br /> r_ <br /> Pit or Grout Inspection by Date_ <br /> Final Inspection by Date <br /> Additional Comments: <br /> El Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 7104 ❑ Tracy 635-6385 <br /> Applicant- Return all copies to: Erivironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009. Stk., CA 95201 <br /> \t <br /> { FEE AMOUNT REMITTED <br /> CK RECEIVED BY DATE PERMIT"NO. <br /> AMOUNT DUE CASH <br /> INFO <br /> a EH 13-24(REV.} H s� -�f�.kA—/ l7 LLl�CC11 rJ <br /> EH 14-26 <br />