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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA. <br /> / Telephone (209) A66-6781 1�.)i <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUES z <br /> (Complete in Triplicate) <br /> •'1opl�cation is heieby made to the ere <br /> San,;naquin Local Health District for a permit to construct and/or install the work herein described.Tli X00" i <br /> r sewage or No. 1862 for well/pump and the Rules,artd Regulations of the San JoaQu n <br /> made in compliance with San Joaquin Cow,v Ordinance No.549 to <br /> Local Health District. ' <br /> r►►�,����_ //���� (CT Lot Size D a M <br /> Job Address�yt�{) QA .i <br /> Address Aaf44=�' rr►�n Phone <br /> Owner's Name r ,�,.,,�..,�..��QQ� <br /> ttres License No.A z4l—/ Phone _ <br /> Contractor <br /> WELL REPLACEM T El DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL �•�: <br /> PUMP INSTAL TI O SYS; REPAIR D O ER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK ER LINES ISPOSAL FLOCOWkPROP. LINE J <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATONS pr <br /> --� Dia.of Well Casing t <br /> In�dustrial IL✓Open Bottom O Manteca Dia. 01 Well Exca tion <br /> L'Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing TypSpoe <br /> Publi <br /> f, Other 1-1 Delta Depth of Grout Seal Type of Groin <br /> rKlatinn ApProx. De th I I Eastern Surface Seal Installed by <br /> Repair Work Done 11 Type of Pump <br /> H.P. �� State Wotk Done fJl <br /> Well Destruction O Well Diameter Sealing Material(top 501 <br /> 'x, <br /> Depth Filler Material (Below 501 $Ysy <br /> TYPE OF SEPTIC WORK: NEW INSIALLATIONI i R'PAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> avbi able within 200 feat.) <br /> Installation will serve: Residence_ Commercial_ Othei <br /> r; <br /> Number o1 living units: Number of bedrooms <br /> Wear table depth <br /> Character of soilto a depth of 3 feet: <br /> rtments <br /> SEPTIC TANK El of Disposal <br /> al <br /> of DisposType/Mfg Capacity No. Co <br /> PKG. TREATMENT PLT. El A <br /> Distance to nearest: We11 Foundation Property Line <br /> t <br /> LEACHING LINE Cl No. h Length of lines Total length/sire O Ix <br /> FILTER BED Ll Distance to neatest: Well Foundation Property Line — ESr <br /> SEEPAGE PITS I I Depth Sire Number gg' ti . �' <br /> E; 1 <br /> SUMPS 1 1 Distance to nearest: Well Foundation Property Line ' ►'. 1ty <br /> DISPOSAL PONDS O (� FX <br /> i� <br /> I hereby certify that I have prepared this application and that the work will be don*in accordance with San Joaquin county ordinances, etate laws, aoQ✓� r <br /> rules and regulations of the San Joaquin Local Health District. C I <br /> Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued,1 shah not <br /> emF.ay any pergon in such manner as to become subject to workman's compensation laws of CalHomia."Connector s hiring a sub contacting signature 'by <br /> certifies the fosowkt�:"1 certify that in the performance of the work for which this permit is Issued,I Stull employ psreom subject to workman's compensa- <br /> tion laws of Cahlrbrnia." �� <br /> The upplie nt st can for at r fired'n"Pactions.Complete drawing on rse side. Q� <br /> Signed Title: Data: <br /> Data: <br /> } <br /> FOR DEPARTMENT USE ONLY 'f <br /> i• <br /> Application Accepted by __ Date <br /> Pit or Grout Inspection by Date 1_A:JJJ Final Inspection by / Date <br /> Additional Comments: <br /> 0 Stk 466.8781 D Lodi 369-3621 ❑ Manteca 823.7104 ❑Tracy 836-M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1801 E. Heretton Ave., P.O. Boz 2009, Stk.,CA 915MI <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMR'No. <br /> INFO <br /> —1124(R[V.1'.%) JS •00 <br /> — t4.M <br /> i <br />