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APPLICATION FOR PERMIT <br /> SAN JOAO,UIN LOCAL HEALTH DISTRICT --; <br /> 1601 E. HAZE T ON AVE.,,STOCKTON, CA h✓�'h�� <br /> v Telephone (209) 466-6781 11 11btol <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i , . <br /> r (Complete in Triplicate) work W.r <br /> application is <br /> t to construct and/or install the <br /> Application is hewith a to the San Joaquin <br /> n County ordinance lIt District549 for sewage o'No. 1862 for well/pump and the Rules and�R gulations of he San <br /> Joaquin <br /> made in compliance <br /> Local Health District: <br /> PM . <br /> City S Lot Size- <br /> Job Address _ <br /> / '�L� � Phone �'� �� '�f�Q0 <br /> Owner's Name I � � � Address/ �] act q <br /> ". one 0(JDI'7 <br /> Address �d License No..3�Ph <br /> Contractor DESTRUCTION ❑ <br /> TYPE OF WAELL/PUMP: EW WELL ❑ WELL.REPLACEMENT <br /> S PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR �9 rOTHER ❑r <br /> ! SEWER LINES __— — DISPOSAL'FLD='"_--PROP• LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> ' <br /> FOUNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS <br /> s INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPEC�FICATkONS– ,,,�, .Dia of Well Casing <br /> b' <br /> ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation <br /> ❑ Industrial. Type of Casing Specifications <br /> X Domestic/Private ❑ Gravel Pack 171 Tracy YP Type of Grout <br /> ❑ Other ❑ Delta Depth of Grout Seal r•-1 <br /> Ll Public Surface Seal Installed by f <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern State Work Done <br /> H.PF ' <br /> '. P.. <br /> Repair Work Done ❑ Type of Pump <br /> Sealing Material [top 50'1 <br /> ![ Well Destruction ❑ Well Diametr faller Materia! {Below 50'} <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION ❑ alYailebptic System <br /> y within200feet.) <br /> itted 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: <br /> Type/Mfg Capacity��-- No. Compartments <br /> ❑ <br /> l <br /> SEPTIC TANK Method of Disposal <br /> ' PKG. TREATMENT PLT. ❑ ` k Foundation Property Line <br /> Distance to nearest: Well <br /> Total lengthlsize- <br /> LEACHING LINE ❑"No. & Length of lines Foundation ' Property Line <br /> FILTER BED ❑ Distance to nearest:. Well <br /> SEEPAGE PITS Ll Depth <br /> Size Number <br /> SUMPS ❑s Distance to nearest: Well <br /> Foundation Property Line <br /> DISPOSAL PONDS ❑ i <br /> thereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Paws, and <br /> rules and regulations of the San Joaquin Local Health District.g <br /> notHome owner aor rson licensed§ agent <br /> n s signlature certifies the s to become subjecrlto workman'srtcompensation lthat in the aws�of California."Contractor's which <br /> ng or this sub contra t ngl signature <br /> employ any p rsons subject to workman's compensa <br /> certifies the fallowing:"I certify that in the performance of the work for which this permit is"ssued, I shall employ Pe <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Date: , <br /> Title: <br /> Signed ' <br /> FOR DEPARTMENT USE ONLY _ 7 �� 4 <br /> � Z11/ � date Area <br /> Application Accepted by Date <br /> I Date Final nspection by <br /> Pit or Grout Inspection by r _ <br /> ddrtional Comments: <br /> f Stk 46fi 6781 odi 3621 ❑ Man 0 eca -823-71 Tracy 835-6386 <br /> A Stk - Return all copies to: Environmental Health3PermitlServices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> A <br /> CK# RECEIVED By DATE PERMITNO. <br /> FEE AMOUNTDUE AMOUNT REMITTED' CASH p� <br /> INFO <br /> r +EH 13-24(REV. <br /> EH 1426 l/ <br />