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APPLICATION FOR PERMIT v i1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �C <br /> 1601 E. HAZELON ON AVE., STOCKTON, CA <br /> kJ <br /> Telephone (209) 466-6781 w <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> y <br /> made tcation is <br /> �the S�Joaquin Lonalncle No,549 for sewage or INo 1862 and/or install the work <br /> and the Rules and(Regulations of the San.This aPP'Joaquin <br /> Application is hereby j <br /> made in compliance with San Joaquin County Ord „ <br /> Local Health District. PM <br /> fYJ� City Lot Size <br /> Job Address _V_11�Tl <br /> Phone <br /> Address — <br /> �1 _ <br /> Owner's Name Z-71-14D Phone � <br /> License No._� <br /> 1 T` Address DESTRUCTION ❑ <br /> Contractor WELL REPLACEMENT ❑ <br />' NEW WELL ❑ OTHER ❑ <br /> TYPE OF WELLIPUMP: SYSTEM REPAIR ❑ <br /> PUMP INSTALLATION ❑ SEWER LINES � DISPOSAL FLO. PROP. LINE <br /> � - <br /> DISTANCE TO NEAREST: SEPTIC TANK � AGRICULTURE WELL <br /> FOUNDATION OTHER WELL.- pIT51SUMPS <br /> " <br /> INTENDED USE TYPE OF WELL PROBL_�M AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing 9\) <br /> ❑ Open Bottom ❑ Manteca <br /> Dia. of Well fzcavation <br /> ❑ industrial Type of Casing Specifications <br /> ❑ Gravel Pack ❑ Tracy Type of Grout <br /> ❑ Domestic/Private r} pelta <br /> I ❑ Other ! <br /> M] Public Surface Seal Installed by <br /> 1 Irrigation .-Approx. Depth I I Eastern State Wark Done ---------- <br /> I H.P. <br /> Repair Work Done ❑ Type of Pump Sealing Material Itop 50'1 <br /> Well.Destruction <br /> ❑ Well Diameter _�-- ; <br /> Depth I filler Material (Below 501 <br /> vailable within 200 feet.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I'1 DES RUCTION INo septic systemrpermitted if public sewer is <br /> installation will serve: Residence Commercial ..-:Other <br /> Number of bedrooms 1 <br /> Number of living units: . , r Water table depth <br /> f Character of soil to a depth of 3 feet: Capacity)-3 No. Compartments <br /> k SEPTIC TANK ❑ Type/Mfg Method of Disposal - <br /> PKG. TREATMENT PLT. ❑ 1 Foundation Property Line <br /> Distance to nearest: Well <br /> } Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Foundation Property Line �1 <br /> r <br /> FILTER BED ❑ Distance to nearest: Well <br /> 0 <br /> Size Number <br /> l SEEPAGE PITS t I Depth iProperty Line <br /> Foundation�— - <br /> SUMPS L] Distance to nearest: Well y <br /> l DISPOSAL PONDS ❑ i <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and � <br /> 11 t <br /> rules and regulations of the San Joaquin Local Health District.g <br /> ` sha no <br /> Home owner or licensed agent's signature <br /> to become subjefollo wlorkman'srtcompensatify that in ion lawsofCalifornian"Contractor's lhir ng or sub-contracting this permit is lsignaturre <br /> r employ any person in such manner as arsons subject to workman's compensa- . <br /> certifies the following: " certify that in the performance of the work for which this permit is issued, I shark employ p <br /> tion laws of C i a !to—in,�� <br /> The applicant u or all required inspections. Complete drawing on reverse side. ! <br /> � Date: <br /> Title: <br /> Sign <br /> � Signed X <br /> FOR DEPARTMENT USE ONLY 1,3I 1 — Date `3 a <br /> a <br /> f Application Accepted by Datl/4� 2___ <br /> Date Final Inspection b <br /> Pit or Grout inspection by <br /> Additional Comments:, ❑ Manteca 823-7104 ❑ Tracy 835 6385 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 Stk., CA 95201 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, <br /> CK RECEIVED BY DATE PERMIT NO. <br /> 1 FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> 1 INFO _^`7- <br /> I r EH 13-24 IREV.t/As <br /> I EH 14.26 <br />