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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE;ISSUED <br /> ` (Complete in Triplicate) ' <br /> he work <br /> Application is hereby made to the San Joaquin <br /> oui ordinance lHealth District <br /> for sewage or for a it to 1862 tconstro 1B62for and/or install and the Rules and rRegulationis <br /> s ai)tis he San application <br /> Joaquin <br /> made in compliance with San Joaquin County <br /> Local Health District. <br /> City Lot Size PM <br /> .lob Address <br /> Phone <br /> fAddress. <br /> Owner's Name f g�. x s: �° 7 r�.�. -- <br /> Phone <br /> License No <br /> Contractor Address r <br /> JNEW WELL WELL REPLACEMENT d DESTRUCTION ❑ v r <br /> TYPE OF WELLIPUMP:. OTHER ❑ " ! <br /> PUMP INSTAL`�LATION SYSTEM REPAIR ❑ p�-� ir <br /> s' ,A� r DISPOSAL FLDISi2� PROP.,LINEC� r <br /> SEWER LINES <br /> i DISTANCE.,TO NEAREST: SEPTIC TANK OTHER WELLS PITS/SUMPS f� <br /> FOUNDATION AGRICULTURE WELL <br /> r ;r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial Bottofi�"` ❑ Manteca Dia. of Well Excavation i <br /> Type of Casing Specifications /lam f <br /> iomestic/Private <br /> 1-1 Gravel Pack El Tracy f Type 'f Grout iG/ tL�t– <br /> k ❑ Delta Depth of Grout Seal <br /> (1 Public Sl Other f ri <br /> rox. Depth l I Eastern Surface Sail Installed by�,�....1 i <br /> I I Irrigation --App . <br /> Repair Work Done ❑ Type of Pump - <br /> H P State Work Dane_ l <br /> , Well Destruction ❑ Well Diameter Sealing Material )top 501 <br /> i fx- <br /> Depth I Filler Material (below 5011 ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I;1 REPAIR/ADDITION 1.1 TRU <br /> DESCTION I 1 (No septic sysihitem pe fee4 t d if public sewer is <br /> lnsjallati_,on will s_e�rve: Residence�—__Commerciai <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. Com meats <br /> SEPTIC TANK ❑ Type/Mfg' Capacity <br /> E Method"of Disposal , <br /> 1 PKG.':TREATMENT PLT. ❑ <br /> Distance to nearest: Well foundation Property Line <br /> f ; }Total length/size <br /> LEACHING LINE• Cf No. f3A� ength-of_lines <br /> f. f Foundation t �' Y Properi;y Line <br /> FILTER ❑`� Distance to-nearest: FWell <br /> Size Number 1 <br /> f SEEPAGE PITS I i Depth Property Line <br /> - -- <br /> SUMPS Cl Distance to nearest: ,Well Foundation v r <br /> �f <br /> DISPOSAL PONDS ❑ { <br /> s I 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 /> rules and regulations of the San Joaquin Local Health District. 1 I a <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 nbt <br /> employ any person in such manner as to become subject to workman's compensatiori laws of California.! Contractor's <br /> snsrsub subject to wong or rkman's gsignature <br /> compensa <br /> certifies the following: '"I certify that in the performance of the work for which this perr"riif Wissued,-1 shall employ p I <br /> tion laws of California." ii S <br /> s �' <br /> The applicant m t tali for all re uire inspections. Complete drawing on reverse sid f <br /> Signed X' <br /> Title: �� =Y-� Date: <br /> F EPARTMENT USE ONLY /► <br /> Data p``��� Area <br /> Application Accepted by <br /> -� Date_-==Y S� Final Inspection by Zfd <br /> Date.' �! <br /> Pit orlGrout Inspection by - -- <br /> I _ s <br /> Additional Comments: . <br /> ❑ Stk 466-6781 O Lodi 369 3621 ❑ Manteca 823 7104 El Tracy 835-6385 <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 r <br /> r FEE CK RECEIVED BY DATE maxel__ <br /> l PUNT DUE AMOUNT REMITTED CASH �. <br /> i INFO <br /> Aw <br /> t EH 13-24 IREV:t/'ri 51 < <br /> =fi. EH 14.28 ' <br />