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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 1209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) application <br /> ll <br /> work <br /> .This <br /> Application is hereby nth Sato the n Joaquin County Ordinance No.District549 for sewage or permit <br /> No. 862 for well/dpump and the Rules and'Regulations of the SJoaquin <br /> made in compliance w <br /> Local Health District. ,I /-y+ <br /> S W City l' Lot Size PM <br /> Job Address T 7 <br /> Q Phone <br /> Address <br /> Owner's Name ,f <br /> Contractor �- NEW <br /> Address <br /> af4Q- O[tiLicense No_ phone <br /> ELL WELL REPLACEMENT TION ❑TYPE OF WELLIPUSYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ <br /> � DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LINES --- <br /> FOUNDATION AGRICULTURE WELL OTHER WELL-Z,5--" PITSISUMPS \ <br /> �f <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Open Bottom fl Manteca Dia. of Well Excavation <br /> ❑ Industrial Type of Casin Specifications <br /> *X Domestic/Private J8(Gravel Pack Tracy <br /> ❑ Public [I Other <br /> ❑ Delta Depth of Grout Seal Tyke of G t �- <br /> ❑ irrigation _--Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump <br /> H P State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ available within o septic e200 feettted if public sewer is <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well Foundation <br /> ` Total length/size <br /> ` LEACHING LINE ❑ No. & Length of lines Property Line <br /> FILTER BED El Distance to nearest: Well Foundation P Y <br /> Size Number <br /> ❑ Depth <br /> SEEPAGE PITS <br /> SUMPS ❑ Distance to nearest: Well Foundation property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin county or ^ L�6 state la , <br /> f- :a r rn <br /> rules and regulations of the San Joaquin Local Health District. i ha - <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this pelissud; l s : fgSt <br /> ' employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or i�ntragtiig sigr�fatg�e <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,l shah employ persons subject wrkmans comlJeliSa <br /> tion laws of California." ;; <br /> The applicant st call for all r wired spections. Complete drawing o reverse si e. p <br /> Signed <br /> Title: <br /> Date: <br /> FO EPART ENT US NLY <br /> 6 -1 � � :rµ <br /> Date re . <br /> Application Accepted by , <br /> Pit or Grout Inspection by <br /> Date LI- — Fin Inspection by Date <br /> Additional Comments: V] Tracy 835 8385 <br /> ❑ Stk 466781 Q Lodi 369-3621 ❑ Manteca &1-71104 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. azelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE K RECEIVED BY ;DATE ;PtERMIT'NO. <br /> INFOAMOUNT DUE AMOUNT REMITTED C H <br /> _7o•oaAPgqazsos� <br /> +EH 13-24 IREV.t i a s> <br /> EH 1428 <br />