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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA v <br /> Telephone (209), 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) applicationcribe . This is <br /> /or install the work <br /> n des <br /> Application is hereby mhade Sanothe Joaquin County Ordinance No.549 for sewage o INo.41862 for cwell/pump and the Rules and IRegulationa of the San Joaquin <br /> made in compliance w"O �Local HealthDC of SizePM <br /> City.Job Address r <br /> Phone <br /> .. _-Address <br /> Owner's Name =„.:.r �72 <br /> erase No._ ✓`-' Phorif <br /> r Address / <br /> y Contractors DESTRUCTION ❑ <br /> k f�� NEW ELL ❑ WELL REPLACEMENT ❑ <br /> S TYPE OF WELL/PUMP: OTHER ❑� �' <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> SEWER LINES -�� DISPOSAL FLD. PROP. LINE <br /> } DISTANCE TO NEAREST: SEPTIC TANK =— AGRICULTURE WELL OTHER WELL Pits/5UMP5' <br /> ,FOUNDATION - <br /> INTENDED USE t T1 PEEOF WELL PRM-----AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing h <br /> Dia. of Well Excavation <br /> �-'L,! Industrial On 8attom ❑ .. Specifications. <br /> f " 1=Gravel Pack ❑ Tracy Type of Casing <br /> r . ❑ DomsticlPrivate Type of Grout <br /> Cl Oher `❑'Delta Depth of Grout Seal . <br /> Cl Putilic s C <br /> Approx?-Depth—l--1-Eastern�«. Surface Seal installed by <br /> ' I I•Irrigation — State Work Done <br /> .,� H.P. <br /> fHepair Work Done ❑ - Type of Pump Sealing Material (top 50'1 F <br /> Well Destruction E] well Diameter ' -�: --.- -” <br /> Filler Material IBelow 50'} <br /> Depth f <br /> IINo <br /> >T,YPE OF SEPTIC WORK: SEW INSTALLATION 11 REPAIRlADDITION l 1 DES 7RUCTION I i availablelc System P wi within 200 feet,Iit public sewer is <br /> P _ <br /> :.o+: installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms !. Water table depth [� <br /> Character of sail to a depth of 3'feet: No. Compartments \U <br /> p,'Type/Mfg apacity�—� — <br /> SEPTIC TANK Method of Disposal <br /> k PKG. TREATMENT PLT. ❑ ( . <br /> Distance to nearest: <br /> Well Foundation Property Line <br /> Total le rrgth l size <br /> - - _ <br /> LEACHING LINE 0' No. & Length of lines ion Property Line <br /> FILTER BED [3, Distance to pearest: ell <br /> ' .. <br /> • Size Nu ber <br /> SEEPAGE PITS I1 Depth <br /> Foundation roperty Line <br /> SUMPS Cl Distance to nearest: Well . <br /> DISPOSAL PONDS ❑ <br /> ccordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and that the work will be done in \ <br /> 'f-=rules and regulations of the San Joaquin Local Health District. work this permit is <br /> ,Home owner or licensed al not <br /> gents signature becomfies the e subject Ito workman's man'srtcompensation lthat in the awsofperformance of <br /> Contractor'srhir ng or sub-contracting ssignlaturre <br /> employ-any person in such manner a <br /> .fcertifies the following: ".I-certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> �� tion laws of California." A f !� <br /> The appl'icent u call for I require inspections. Complete drawing on reverse side. <br /> „ Title: Date: <br /> I Signed X " a <br /> FOR DEPARTMENT USE ONLY <br /> Date ` <br /> t 3 Area l •L <br /> i <br /> Application Accepted by _ Date[L_f� 3 <br /> ,/ <br /> eel, <br /> Pit Grout Inspection by . <br /> atteo rival Inspection by <br /> /' f ��-�F-• , <br /> Additional Comments: <br /> E] Stk. 466-6781,,-..---Q--Lodi 369-3&21 ❑ Manteca s ❑ Tracy 835-6M5 <br /> Applicant - Re umhall-copies tri: Environmental Health Permit/SServicervic es 1601 E. Hazelton Ave., P.O. Sox 2009, Stk., CA 95201 <br /> PERMIT'NO. <br /> 1 CK RECEIVED BY DATE <br /> EE' MA NDUE AMOUNT REMITTED CASH A <br /> INFt�FO . � � r< f <br /> 1. _ T <br /> EH 13-24 o © G <br /> 7.0 > <br /> r (REV.�/µ51 <br /> EH 7426 <br />