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APPLICATION FOR PERMIT <br /> � $ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> ;PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> plicate) <br /> Tri <br /> (Complete In p . This application <br /> is <br /> /or install the work <br /> Application is hereby made to the San Jaaqur O dlnalnce No.549 for sewage or permit <br /> Na 1862 for welUpump and the Rules and(Regulations of the San Joaquin <br /> made in compliance with San Joaquin County I 1 <br /> Local Health District. t t� PM <br /> 4E.- City"' Lot Size . <br /> Job Address -) <br /> /j t , I7�a 8 [Je- 3I71►�+ Phone <br /> Address 6L ^ ! <br /> Owner's Nam -'� --� �K 7A69: f <br /> 40e License N �T��Phon <br /> C � i / Addre DESTRUCTION ❑ <br /> Contractc� WELL REPLACEMENT ❑ <br /> TYPE OF WELLIPUfAP: NEW WELL ❑ OTHER ❑ <br /> Y--""� SYSTEM REPAIR ❑ <br /> Pl0MP-INST4LLATION ❑ DISPOSAL FLD. PROP. LINE <br /> ' SEWER LINES ��-- pITSISUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK �� AGRICULTURE WELL OTHER WELL <br /> FOUNDATION _�� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation fi <br />+ <br /> L1 industrial Specifications <br /> i ' - ❑ Tracy Type of Casing <br /> ❑ Domestic lPrivate ❑ Gravel Pack Type of Grout <br /> Cl Other n Delta Depth of Grout Seal r <br /> (-I Public Surface Seal installed by 1/!1 <br /> Approx. Depth t 1 Eastern State Work Done_ <br /> I 1 Irrigation r H.P. <br /> Repair Work Done ❑ Type of Pump ��— <br /> i Sealing Material (top 501 <br /> Well Destruction ❑ Well Diameter <br /> gl Filler Material (Below 50'} <br /> } Depth . <br /> t TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIRlADD1T10N l 1 DESTRUC710N aNailable1wit m 2pp feet.) if.public sewer is <br /> Installation will serve: ' Residence� Other Commercial� y <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: Capacity— No. Compartments M <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ ,. Foundation_�— Property Line <br /> Distance to nearest: Well r <br /> Total lengthlsize <br /> ❑ No. &Length o1 lines <br /> LEACHING LINE Foundation__-- — Property Line <br /> l FILTER BED ❑ Distance to nearest: Well <br /> r Size Number <br /> SEEPAGE PITS 4 1 Depth Property Line <br /> I L� Distance to nearest: Well foundation <br /> l SUMPS <br /> DISPOSAL PONDS ❑ <br /> I <br /> r 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, an <br /> rules and regulations of the San Joaquin Local health District. I certif that in the performance of the work for which this permit is issued, I shall not <br /> T <br /> Home owner or licensed agent's signature certifies the following:." Y <br /> employ any person in such manner <br /> f n that n to the perfoemance of othe wok fof which this permit is issued,I shall emploty perrsonnsation I <br /> slsubject rto workman's sub-contracting <br /> l certifies the following. Y <br /> tion laws of California." <br /> r The applicant must call for all required inspections. complete drawing on reverse side. p r <br /> Date: Oti <br /> Title: <br /> r �Signed Y��— - <br /> FOR DEPARTMENT USE ONLY _ <br /> I Date Area <br /> Application Accepted by ! to <br /> } ' Final Inspection by <br /> Pit or Grout Inspection by } pate _ <br /> I 3~ Q <br /> Additional Comments: <br /> E3Stk 466-6781 Lodi 369-3621 LJ mania 823 7104 ❑ Tracy 835-6385, P.O. Box 2009, Stk., CA 95201 <br /> l Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., . <br /> - <br /> RECEIVED BY DATE PERMIT'NO. <br /> I FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO <br /> a EH 13-24 1REV.1/n 5) <br /> EH 14.28 <br /> i <br />