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F ! <br /> APPLICATION FOR PERMIT w <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA s <br /> _ Telephone (209) 466-6781 <br /> I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED " <br /> (Complete in Triplicate) <br /> a work <br /> cation is <br /> all th <br /> Application is hereby made tot he San County Ordinance Health <br /> District <br /> for sewage or permit <br /> cons for well construct and/or <br /> purrli end the Rules and herein <br /> Regulations of tthe San is l Joaquin <br /> made in compliance with San q <br /> i Local Health"District. <br /> 'All IPD Lot Size PM <br /> /� �. City <br /> Job Address <br /> (GRkPil CAAIOvl' � Phone 3'Cad/ <br /> Address <br /> Owner's Name W/F� <br /> �fLicense No. MY19—phone <br /> 5 Address <br /> Contractor DESTRUCTION <br /> TYPE OF WELL/PUMP: y NEW WELL ❑ WELL REPLACEMENT ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> j PUMP INSTALLATION LlPROP. LINE <br /> DISPOSAL FLD. <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES ! <br /> "I FOUNDATION AGRICULTURE WELL ' OTHER WELL PITS/SUMPS <br /> I INTENDED USE TYPE OF WELL PROBLEM AREA CONST RUCTION!SPECIFICATIONS pia. of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> I -3Industrial " Specifications <br /> L1 Domestic I Private Et Gravel Pack ❑ Tracy Type ofICasing <br /> Type of Grout <br /> I'1 Public Cl Other V r <br /> Delta' / Depth of Grout Seal _ <br /> 1 Irrigation __Approx. Depth t'i Eastern Surface eel Installed by <br /> f Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> ; <br /> Sealing Material It6p 50'1 <br /> Well Destruction ,OV Well Diameter _ '" <br /> 7 Filler Material (BeIoW 50'1 <br /> � Depth - <br /> TYPE OF SEPTIC WORK:__.NEW_INSTAL-L-AT-ION;I-I --REPMWADDITION i !a DESTRUCTION-t-I-(Noilabpel -syst 200 feepermitted-if-public"sewer is <br /> installation will serve: Residence— Commercial Other <br /> Number of living units:_ .Nu mber_of-bedrooms ,.��.--- s-= --^ Water table depth � � A <br /> t <br /> Character of soil to a depth of 3 feet: No. Compartments 4 <br /> SEPTIC TANK ❑ Type/Mfg <br /> Capacity <br /> i J 1 Method-oi Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Pro arty,Line- _ '— <br /> Total lengthlsize <br /> LEACHING LINE 0' No. & Length of lines Property Line <br /> FILTER BED ❑ Distance to nearest: Well Foundati� Pe Y <br /> I i Depth Size � �} �__ zNumber <br /> SEEPAGE PITS i <br /> Property Line <br /> SUMPS CI Distance to nearest: Weil Foundation F p Y <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that ! 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 /> I Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not <br /> ."Contractor'sring or <br /> signature <br /> employ any person in such manner as to become subject to workman's compensation laws of California <br /> certifies <br /> ect to orkmant1s compensa <br /> certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall employ p f <br /> 1 tion laws of California." <br /> The applicant r requir tions. Complete drawing on r ers side. <br /> Title: Date: <br /> 4zr,� <br /> Signed X <br /> i <br /> FOR DEPARTMENT USE ONLY �$ <br /> Date ` Area <br /> Application Accepted by <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Data <br /> Additional Comments: v <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CK RECEIVED BY GATE PERMIT NO. <br /> FEE <br /> AMOUNT DUE AMOUNT REMITTED GASH <br /> INFO <br /> + EH 13-24 IREV.I/H 5) <br /> CH 14-2a <br />