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APPLICATION FOR PERMIT <br /> SAN JOAO.UIN LOCAL HEALTH DISTRICT <br /> ES 1601 E. HAZELTON AVE., STOCKTON, CA <br /> -Telephone (209) 466-6781 y <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> lCamplete in Triplicate) I s <br /> ealth <br /> ! 3:y � .s , <br /> n is <br /> Application is hereb w th Sano the San <br /> JoaquinCountyaqui Ordinance No.District549 for sewage or permit <br /> 1862 for cwell tlpump and the Rules and Regulationswork herein d of the S.This an Joaquin <br /> ' made in compliance <br /> Local Health District. c ,r/ o Y_) PM <br /> f .'l r rnh"��r! City 5 �f Coott Size <br /> Job Address S _ �rs� <br /> •Owner's Nam <br /> Address': �r �� :dz. Phone <br /> - t � Address <br /> License No. Phone <br /> Contractor �' DESTRUCTION ❑ <br /> NEW WELL ❑ WELL REPLACEMENT ❑ <br /> TYPE OF WELL/PUMP: . SYSTEM REPAIR ❑ OTHER <br /> PUMP INSTALLATION ❑ <br /> I DISTANCE TO NEAREST: IC TANK <br /> SEWER LINES DISPOSAL_FLD: PROP. LINE <br /> PITS/SUMPS <br /> FOUNDA AGRICULTURE WELL OTHER WELL <br /> INTENDED'USE TYPE OF WELL EM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Excavation Dia. of Well Casing <br /> { <br /> El Industrial El open Bottom ❑ a Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type o $sing <br /> ❑ Delta Depth of"Grouf Seal Type of Grout <br /> ❑ Public El - <br /> �pprox. Depth ❑ Eastern _Surface Seal Installed by <br /> ED Irrigation — H.P._ State Work Done <br /> T <br /> Repair Work D ❑- .TYpe of Pump „ Sealing Material (top 50') <br /> Well D uction .❑ Well Diameter <br /> "4 Depth I Filler Material (Below 501 <br /> l <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION available�within e200 feet. <br /> ) sewer is <br /> Installation will serve: Residence's Commercial— Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3�feet: No. Compartment <br /> SEPTIC TANK:. ❑ TYpe/.Mfg Capacity— Method of Dispos <br /> PKG. TREATMENT PLT. ❑ <br /> Property Line <br /> Distance to.nearest: Well <br /> Foundation <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of linesFoundation ` Property Line <br /> FILTER BED El Distance to+nearest: Well <br /> ti ❑ Depth Size "" Number <br /> SEEPAGE PITS Property Line <br /> SUMPS ❑ Distance to nearest: Well Foundation s <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:lavus, and <br /> rules and regulations of the San Joaquin Local Health District. work for <br /> certify that in the l not <br /> Home owner aor rson insuch manner as turbecomees the ft lto workman's compensation laws of Califrmanceornia."Contractor's which this <br /> or sub-contracting lsignlature <br /> employ any p <br /> certifies 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." <br /> The applicant st c fo all required in pections. Complete drawing on reverse side. <br /> Title: U w~`�- :Date: <br /> Signe <br /> FOR DEPARTMENT USE ONLY <br /> Date Z Area <br /> Application Accepted by <br /> Pit or Grout Inspection by Date <br /> Final inspection b ate <br /> i Additional Comments: <br /> 1 ❑ Stk 466-6761 C1 Lodi 369-3621 ❑ Manteca 623 7104 ❑ Tracy 635 6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.. P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED H <br /> RECEIVED BY DATE <br /> INFO PERMIT NO. <br /> + EH M241REV.1/851 <br /> i EH t4-26 <br />