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t� <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 'l <br /> (Complete in Triplicate) This <br /> construct and/or <br /> ll'the work <br /> rein <br /> bad <br /> Application is hereby made to thnJoaquin County LocalHealth nce No.District <br /> far sewage or Nocation is <br /> rmit . 1862 for we <br /> Local <br /> and the Rules and Regulations of the Sian Joaquin <br /> made in compliance with San Joaquin / <br /> Local Health District., <br /> �. of Size PM <br /> City <br /> Job Address <br /> Phone <br /> Owner's Name <br /> Address <br /> �cJ a License No, Phone <br /> f � t: dress + <br /> Contractor WELL REPLACEMENT ❑ DESTRUCTIOLN0_ <br /> TYPE OF WELL/PUMP: �' NEW WELD OTHER ❑ t E <br /> .:y PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> • �».- DISPOSAL FLD. PROP."'LINE, <br /> SEWER LINES E <br /> 13ISTANC£TO NEAREST: SEPTIC TANK OTHER WELL— <br /> FOUNDATION <br /> f" FOUNDATION — AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation s <br /> ❑ Industrial T of Casing Specifications: <br /> :: <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Y!� Type of Grout' \ <br /> ❑ Other ❑ Delta Depth of Grout Seal <br /> l ❑ Public Surface Seal Installed by <br /> C1 Irrigation '-L—Approx. Depth [I Eastern State Work Done 4 <br /> H.P. <br /> Repair Work Done Ll Type of Pump �— 50' f <br /> Sealing Material IP to 50')i r <br /> Well Destruction ❑ Well Diameter { g <br /> Depth !Filler Material IBelow 501 , <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPA+RIADDITION ❑ DESTRUC VON ❑ avail blesep 1within 200 feettted.rf public sewer is. { <br /> rl Commercial 4 Other <br /> r Installation will serve: Residence— <br /> Number of living units:— - Number of bedrooms <br /> l f Water table depth 4 F <br /> Character of soil to a depth/of 3 feet: # opacity = 1— No. Compartments <br /> SEPTIC TANK C- Type/Mfg ,� Method of Dispo�l <br /> PKG. TREATMENT PLT. ❑ / <br /> Distance to nearest Well <br /> Foundation Property tine <br /> Total lengthlsize 1 <br /> LEACHING LINE f�do• & Length of lines F <br /> lWell,— <br /> FILTER <br /> Foundation Property Line •' <br /> FILTER BED ❑ Distance to nearest: Wella <br /> J � t <br /> Number i <br /> SEEPAGE PITS 5e Depth —2 j—Size' n i" ! <br /> r Foundation — ProPattl' Line <br /> SUMPS L1, Distance to nearest: Well , <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that l have prepared this application`and that the work will be done in accordaneewvith-San Joaquin�county�ord'mances,-state,eves, an <br /> rules and regulations of the San Joaquin Local Health District. I certify that n the performance of the work for which this permittis issued, I shall not <br /> Home ov4h;r-or•lieensed'agent,s signature certifies the fallowing: " <br /> "" ersons sub'ect to workman's cbmpensa <br /> employ any person in such manner as,to become subject to workman's compensation laws of California."Contractors hiring.`or sub contracting signature <br /> certifies the following:"I certif�i.that in the performance of the work for^which this permit is issued,I shall employ p I <br /> s 2. ,rx <br /> t tion laws of California." # _ � <br /> The..applicant st 11 far,al quired,ipections. ComQlete drawing on reverse side. <br /> f <br /> = Is � ��� a Title: �' Date,,.T <br /> Signed <br /> i <br /> FOR REPA TMENT USE ONLY <br /> ` Area <br /> Date <br /> Application Accepted by Date U <br /> Pit or Grout-In-Action by Date Final Inspection by <br /> g .F Additional Comments: ca 823 7104 ❑ Tracy <br /> i <br /> ❑ Stk 466-6781• ETLodi 369-3621 [1Mante835 6385 <br /> x <br /> Applicant Return copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 <br /> CK RECEIVED BY DATE PERMIT''NO. <br /> -FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> � INFO <br /> + EH 13-24(REV.1/0 5) <br /> EH 14-28 <br />