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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTION AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r <br /> (Complete in Triplicate) <br /> described.This <br /> madeApplication <br /> in coT fiance with San othe Joaquan County On Joaquin rd nance No.Districtocal Health 49 for sewage permit <br /> r11No. 1862 forcweilapump install <br /> nd the Rules and fReguiations of the San'Joaquin <br /> . made in compliance <br /> Local Health District. <br /> ° City QC /Cot Size PM <br /> Job Address —� <br /> f -��n Phone <br /> Owner`s Name Address ! <br /> Address License No. <br /> Phone <br /> Contractor DESTRUCTION <br /> TYPE DF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION C] SYSTEM REPAIR Ll <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> AGICULTURE WELL OTHER WELL PITS/SUMPS <br /> R <br />� FOUNDATION _ ---- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation r Specifications <br /> Type of Casing ` <br /> j ❑ Domestic/Private [:1 Gravel Pack L3 Tracy Depth of Grout Seal t Type of Grout <br /> [I Public L] Other ❑ Delta <br /> r F� <br /> ❑ ---Approx.�pprox. Depth E3 Eastern Surface Seal Installed by <br /> H P State Work Done <br /> L Repair Work Done ❑ Type of Pump ; <br /> If Sealing'Material{top 50'1 (� <br /> Well Destruction L] Well Diameter I f <br /> Depth Filler Material'(Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ R`EPAIR/ADDITION ❑ DESTRUGTION ❑ avlailabfelwt system 200 feet.) if public sewer iso <br /> ar t� <br /> Installation will serve: Residence <br /> Comme � j <br /> Number of living units: Number of bedr oms'• e. ater table depth <br /> character of soil to a depth of 3 feet: r' �- "Y`—~ <br /> i � m�� Capacity o. Compartments - <br /> SEPTIC TANK ❑ Type/Mfg expired �d <br /> l r Method of Disposal <br /> PKG. TREATMENT PLT. ❑ `W;r a <br /> WO!"� �0' <br /> 0� ` '' ' Property Line <br /> Distance to nearest: �t,WeAl iY O <br /> if gth/size <br /> I LEACHING LINE ❑ No:& Length of lines - f <br /> Foundation "Property Line w"' <br /> FILTER BED ❑ Distance to nearest: Well .j <br /> s <br /> Size Number <br /> SEEPAGE PITS [I Depth <br /> Depth Property Line <br /> I SUMPS ElDistance 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 /> I <br /> rules and regulations of the San Joaquin Local Health District. p <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.shall not <br /> i that <br /> ws'of-Calif s -hiring <br /> emfsca ttc <br /> Ice certify tha n the performance he wok for which permtissed, hall employ persons subject to wormansmpe <br /> certifies the following; <br /> hsa <br /> tion laws of California." f ' <br /> I <br /> The applicant must 1 s ctions: complete drawing on reverse side. <br /> ` Date: y <br /> Title: <br /> Signed X � •�,.- , <br /> FOR DEPARTIMENT'USE-ONLY 1� <br /> Date rT y.Area <br /> Applicatior_i Accepted by, <br /> Final In�tion by Date <br /> Pit or Grout Inspection by Date _- <br /> . �F y - �j <br /> Additional Comments: 6385 <br /> ❑ Stk 466-6781 Ll Lodi 369-3621 El Manteca 823-7104 L1Tracy 835 Stk., CA 95201 �. n <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, <br /> CK RECEIVED BY DATE PERMIT � <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> .. I1 � r/L..f)`(//- <br /> I 'Irl. 3 5 5- <br /> + EH i3-24 1REV.t/n <br /> EK 14.28 - <br />