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f <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) work herein <br /> .This <br /> Application is hereby macatim is <br /> de to tCounty Ordinance No.District549 for sewage or permit <br /> No. 1862 for well/pump install <br /> nd the Rules and Regulations of the Sawn'Joaquin <br /> made in compliance with San Joaquin <br /> Local Health District. i <br /> ���� City tot Size PM <br /> Job Address I _ T a7� <br /> - Address Phone <br /> Owner's Name <br /> aS+ <br /> License No.�-.--Phone <br /> Contractor _ Address F--- <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT Ll DESTRUCTION ❑ <br /> PUMP INSTALLATION L1 SYSTEM REPAIR ❑ OTHER . $J6 / <br /> h10 DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK J SEWER LINES PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing O <br /> rl yal n„ro�uWC Open Bottom d Manteca Dia. of Well Excavation Specifications <br /> 9�— T e of Casing <br /> El Domestic/Private ❑ Gravel Pack 0-Tracy e1 Depth of Grout Seal Type of Grout <br /> Qther <br /> i <br /> El Public r <br /> ❑ Irrigation �a=.f�pprox. Depth ❑ Eastern Surface Seal Installed by <br /> Type of Pump H.P. State Work Done <br /> [Iu � <br /> Repair Work Done _ Sealing Material Itop <br /> f <br /> Well Destruction 7sc�� Well Diameter <br /> Depth q Filler Material {Below <br /> { TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION 0 aNailabPe�wshtem permitted 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: Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT.❑ Property Line <br /> Distance to nearest: Well Foundation p y <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of fines Foundation Property Line <br /> FILTER BED L] Distance to nearest: Well <br /> Number <br /> SEEPAGE PITS L3Depth <br /> Size <br /> SUMPS ❑ 'Distance to nearest: Well <br /> Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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. <br /> g work for <br /> Home owner eorr Tice ilssu h manner as tore become esubject the Ito workman'srcompensation laws ofy that in the performance <br /> Californ aha Cont actor sIh ng1 orr sub contractinglsignature <br /> employ any <br /> certifies the following:" certify that in the pert nee of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> + tion laws o California.' 11_ /) 11 <br /> !E The applic n must cal for al equir spections. Complete drawing n r verse side. <br /> Title: 1'l! Date: v <br /> Signed - <br /> FOR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by <br /> Pit or Grout Inspection Date <br /> Final Inspection by Date <br /> Additional Comment <br /> ❑ 5tk 466 6781 ❑ Lodi 369-3621 ❑ Man 823-7 0 1601 E0 Tracy eiton Av P. - ox 2009, 5 A 95201 <br /> Applicant <br /> Return all copies to: Environmental Health Permit/ <br /> CK <br /> FEE AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT N0. <br /> INFO �f <br /> 39'* <br /> j <br /> + EH 13-241REV.t/651 1 <br /> EH 14-25 J _.... - <br />