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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 /> 4 and the Rules and Regulations of the San Joaquin <br /> jor <br /> AppH <br /> cation is hereby made to the San Joaquin Local Health District i t sewage or <br /> permit <br /> 1862 forcwe well/ stall the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance N <br />! <br /> Local Health District. � , f � PM I <br /> •.�� � J��,Li/ <br /> i <br /> Job Address ize/ L Phone <br /> 4/� Address <br /> Owner's Name <br /> (�f <br /> �W I_icense,No-, — =Phone. <br /> Address <br /> �►. Contractor WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: J Nk�h!WELL ❑ OTHER ❑ <br /> SYSTEM REPAIR ❑ PROP. L1NE <br /> PUMP INSTALLATION,❑ DISPOSAL FLD. <br /> Z _ SEWER LINES -- PITS/SUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK" AGRICULTURE WELL OTHER WELL— <br /> PROBLEM <br /> ELL p. <br /> " FOUNDATION --- �1 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> ` — open Bottom; Q Manteca Dia. of Well Excavation <br /> ❑ Industrial Specifications <br /> ❑ Gravel Pack ❑ Tracy Type of Casing <br /> 11❑ Domestic/Private Type of Grout <br /> I ❑ Other- - ❑ Delta Depth of Grout Seal <br /> ❑ Public } Surface Seal Installed by 1� <br /> E] Irrigation f _Approxi Depth ❑ Eastern State Work Done <br /> H.P. <br /> Repair Work-Done, ❑Type of Pump Beaking Material (top 501 <br /> Well Destruction ❑ Well Diameter Filler Material (Below 501 <br /> l/ Depth <br /> available within 200 feet.) <br /> TYPE OF SEPTIC WOR : ;NEW INSTALLATREPAIR/AD <br /> ION DITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is <br /> Commercial Other 4 <br /> Installation will serve: Residence I <br /> ' Number of bedrooms <br /> Number of living units: _�— Water table depth. <br /> ` Character of soil to a depth of 3 feet: ,/, Capacity — No, Compartments00 F <br /> SEPTIC TANK ❑ Type/Mfg 1 I Method of Ujsposaly�� <br /> PKG. TREATMENT PLT. ❑ t <br /> �_ Foundation Q Property Line y <br /> Distance to nearest: WeN r <br /> i <br /> ` .Z l+ (Total I ngihlsize l } <br /> ❑ No. & Length of lines yy��� Property Line <br /> LEACHING LINE <br /> FILTER BED ❑ Distance to nearest: Well n <br /> l — <br /> Size Number <br /> SEEPAGE PITS ED Depth Foundation' Property Line <br /> SUMPS El Distance to nearest: Well %- <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. that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifiel the following: "I certifylaws of tune <br /> employ any person in such mannerthbecome <br /> oiiorm sation <br /> ubject <br /> ofthe-work for which this permit is issued,.I shall-emptoypeorsonsrsubject to orkmanlseompensa <br /> Certifies ttie fallowing: "I certify thatPe <br /> tion laws of California." <br /> The applica t call for all r re spections. Complete drawing on reverse side. f- <br /> ' � � Title: <br /> U-J r Date: <br /> Signed i 1 ! <br /> FOR DARTM/E�NT�/US NLY1-3 <br /> t'�f' /q/i"' ate Area 4 <br /> Application Accepted by r Date <br /> Date Final Inspection by r . <br /> Pit or Grout Inspection by �» <br /> Additional Comments: ❑ Lodi 3693621 ❑MaIntece 823-7104, ,,'; ❑ Tracy 835-6385 Stk., CA 95201 <br /> ❑ Stk 466-6781 <br /> 009, <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2 <br /> RECEIVED 8Y DATE PERMI-CNO. <br /> FEE AMOUNT DUE AMOUNT REMITTEDCASH <br /> INFO <br /> + EH 13-24(REV.1/85) <br /> EH 14-26 <br /> 7 <br />