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rw <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601E E HAZION AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> j (Complete in Triplicate) location is <br /> 9 for sewage r No. con fart and/or i and the Rules and Regulations of the San Joaquin <br /> is hereby made to the San Joaquin Local Health <br /> District for a permit to construct and/or install the work herein described. This app <br /> Application Joaquin County Ordinance , <br /> made in compliance with San <br /> Local Health District. Lot Size PM <br /> 7S t City -• Q <br /> Job Address L q �Phone I ! Q <br /> Address <br /> Owner's Name -�- ?Phone <br /> License No <br /> 4 d ssDESTRUCTION ❑ <br /> Contractor WELL REPLACEMENT ❑ <br />� NEW WELL ❑ OTHER ❑ <br /> * TYPE OF WELLIPUMP: SYSTEM REPAIR ❑ PROP LINE <br /> PUMP INSTALLATION ❑, DISPOSAL FLD. <br /> f SEWER LINES -- PITSISUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK —�— OTHER WELL <br /> FOUNDATION <br /> AGRICULTURE WELL <br /> TYPE OF WELL PROBLEM AREA ?CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> INTENDED USE Manteca 'iia•-of'Well.Excavation <br /> ❑ ❑ <br /> ` <br /> Open Bottom -f, Specifications V <br /> j <br /> El industrial ❑ Tracy Type of Casing <br /> ❑ Domestic/Private ❑ Gravel Pack rout Seal Type of Grout -- -- <br /> EI Delta Depth o.G } ` IN <br /> M Public ❑ Other a <br /> Surface Seal.Installed by <br /> I 1 Irrigation Approx. Depth l 1 Eastern /,-e � J, " State Work Done <br /> I e of Pump �� H.P. X. + f .' <br /> Repair Work Done ❑ Type Sealing Material{top 50'!r, :fir <br /> r Well Destruction ❑ Well Diameter ! 0" <br /> Depth Filler Material (Below 50,) <br /> U EPAIfllA,DDITION l':} DESTRUCTION I I Ili sblerwihine200 feettled if public sewer is <br /> { TYPE OF SEPTIC WOflK: NEW INSTALLATION <br /> Il "\\XOther <br /> Commercial �- <br /> I <br /> installation will serve: Residence— <br /> Number of living units: <br /> 'Number of bedrooms ; Water Sable depth <br /> Character of soil to a depth of 3 feet: 4F Capacity.. No. Compartments C <br /> SEPTIC TANK ❑ Type/Mfg �' Method of Disposal <br /> Pi TREATMENT PLT. ❑ Foundation Property Line l l} <br /> I Distance to nearest: <br /> Well N $ <br /> I <br /> Totakdength/size <br /> ` LEACHING LINE ❑ No. & Length of lines Property Line <br /> r Foundation <br /> FILTER BED ❑ Distance to nearest: We L_—`+ <br /> i <br /> _ Number <br /> SEEPAGE PITS I I. Depth iI Size C� Property Line <br /> SUMPS Ll Distance to nearest: Well <br /> Foundation <br /> DISPOSAL PONDS ❑ i <br /> f l hereby certify that I have prepared this application and that the work wi11 be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. I certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: " y arsons subject to workman's compensa <br /> employ any person in such manner hat n the perm mancecof he work for whichehss permit is issuedifl shall employ ptor s hiring or subcontracting signature <br /> ' certifies the following: "I certify <br /> tion laws of California." on reverse side. <br /> The applicant m t call for all to red inspe tions. Complete drawing .- <br /> p pate: <br /> Title: <br /> Signed X �] <br /> OR DE ENT USE ONLN <br /> Date <br /> i Area <br /> Application Accepted by / <br /> Date,� � <br /> ate_.�� Final inspection by <br /> Pit or Grout Inspection by ,- <br /> Additional Comments: ❑ Tracy 835•-6385 w� <br /> ❑ Stk 466-6781 1❑ Lodi 369 3621 ❑ Manteca Ser 7104 <br /> ` <br /> Applicant - Return all copies to: Environmental He <br /> atth Permit/Services 1601 E. Hazelton Ave., P.O`FBox.2009, Stk., CA 95201 <br /> CK RECEIVED BY DATE PERMIT NO. <br /> 1 , FEE MOUNT DUE AMO <br /> REMITTED CASH 00 I�T <br /> INFO <br /> . EH 13-24{REV.r/n 5) <br /> EH 14-26 <br /> ■ <br />