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}� APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT t <br /> 1601 E. HAZE'.TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 I <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> and/or install the work herein described. This application is <br /> Application is hereby <br /> made to the San Joaquin.Loca1 Health District for a permit to construct <br /> made a compliance with San Joaquin County Ordinance lth District <br /> for sewage r No. 1862 far well 1pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> C r� Lot Size PM <br /> of City <br /> Job Address <br /> Phone <br /> I Owner's Name , <br /> Contractor S ddress <br /> DESTRUCTION <br /> License No. � 1 Phone <br /> WELL REPLACEMENT ❑ ❑ <br /> NEW WEL <br /> f TYPE OF WELL/PUMP: OTHER EJ INSTALLATION SYSTEM REPAIR ❑ <br /> DISPOSAL FLD.,,Z:: ,.CROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK d0 SEWER LINES . pITS1SUMPS — <br /> 1� AGRICULTURE WELL OTHER WELL <br /> i FOUNDATION �.[�— --. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION pia. of Well Casing <br /> ❑ Industrial ;�J <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation G Specifications <br /> ravel Pack ❑ Tracy Type of Casing <br /> pomesticlPrivate /� Type T Grout <br /> Cl Other f 1 Delta Depth of Grout Seal <br /> {-1 Public Surface Seal Installed by <br /> l aAppfox.� Depth ti Eastern <br /> "I l Irrigation H.P. P, State Work Done— <br /> � <br /> Repair Work Done L7 Type of Pump -5dAc <br /> Sealing Material (tap 50'1 <br /> Well Destruction ❑ Well Diameter —_ <br /> Depth Filler Material iBelow 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l 1 DESTRUCTION l 1 alvailablesept'w thin 200 feet.) if public sewer is <br /> Installation will serve: Residence <br /> Commercial— Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> PKG, TREATMENT PLT.❑ Property Line <br /> Distance to nearest: Well Foundation P V <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Property Line <br /> FILTER BED <br /> LJ Distance to nearest: Weil Foundation <br /> 1 Size Number j <br /> I SEEPAGE PITS i I Depth property Line <br /> SUMPS �.- �-- <br /> ❑ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ <br /> hereby certify 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. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I si <br /> signature <br /> he not <br /> nsation <br /> s of <br /> employ any person certifies the following: <br /> such <br /> certify that n the perfomancect to of he wok for which this permit is issued,fI shall employ personsactors subto workmanring or `scompensa- <br /> g: .. <br /> tion laws of California." r <br /> The applicant m I rag 'ed inspe s plete drawing on reverse sides ' <br /> js// Date: <br /> Signed X <br /> OR DEPARTMENT USE ONLY <br /> � � firj <br /> Application Accepted by Date Araa�� ate <br /> Date/� Final Inspection by r -- L��( -�1S] <br /> r Pito ro Inspection by r _ / f <br /> Additional Comments: <br /> ❑ Stk 466-6781 El Lodi 369-3621 ❑ Manteca 623-7104 IJ Tracy 835-6385 <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. sox 2009, Stk., CA 96201 <br /> CK RECEIVED 8Y DATE PERMIT Na. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> le r -� - - <br /> + EH 13-24;REV. a 5) - � <br /> EH 14.28 � � '\ � �� <br />