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a <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE-, STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Ith District for a , This app <br /> cation is <br /> Application is hereby made to the San Joaquin LdonalHea nce No.549 for sewage or permit <br /> No. 1862 for cwe[Upump and the Rules and Regulatiot and/or install the work herein ns of the San f Joaquin <br /> made in compliance with San Joaquin County Or �� j <br /> Local Health District. Ia at to4r <br /> 1 City Lot Size Aatow PM <br /> Job Address Jr <br /> Phone S ;� <br /> • Address <br /> Owner's Name <br /> License No.��.Phone <br />` Contractor �re , <br /> NE WELL REPLACEMENT ❑_ DESTRUCTIION..0 <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> j <br /> t <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO !S <i <br /> i /rl Jy Dia. of Well Casing 3 <br /> © industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation�_� -- Specifications Se d-1-40 <br /> Type of Casing t <br /> ❑ Domestic/Private Gravel Pack ❑ Tracy Depth of Grout Seal Type of Grout <br /> FI I Public Cl Other 116M /� F1 Delta <br /> --Approx. Depth I 1 Eastern Surface Seal Installed by i <br /> I I Irrigation State Work Done , <br /> Repair Work Done d Type of Pump H.P. <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> { <br /> h Filler Material (Below 501 <br /> '1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION tl REPAIR/ADDITION l I DESTRUCTION I 1 septic system permitted if public sewer is <br /> available.within 200 feet.l f f <br /> j Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> +-�— _C_apacity n - <br /> SEPTIC TANK El Type/Mfg <br /> Method at Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well 1 Foundation Property Line s yfi <br /> 1, <br /> thlsrze <br /> LEACHING LINE LI No. & Length of lines Total-length ..;r <br /> FILTER BED ❑ Distance to nearest: Well Foundation ' * ° Property Line <br /> s: <br /> SEEPAGE PITS i I Depth Siza Number <br /> ' `"ti Foundation Property Line <br /> SUMPS Ll Distance to nearest: Well <br /> f '.,;- ...."..y _-""" T <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. 1 <br /> 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, I shall.not <br /> signature <br /> employ any person in such manner as to become subject to workman's compensation taws of California." Contracgonstsuti ect to oring or akman'rscompensa <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ p j <br /> tion laws of California." <br /> The applicant must or ail r iced ns 'ons. Complete drawing on reverse side. <br /> # t Date: <br /> Title: <br /> Signed X j • Y <br /> # FOR DEPARTMENT USE ONLY <br /> Date <br /> Area <br /> Application Accepted by <br /> LAJ `Date Final Inspection by <br /> Pit or Grout Inspection by <br /> Data <br /> Additional Comments: i <br /> ❑ Stk 466-6781 anteca-823-71 odlio ❑ Tracy 835-6385 t <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.-Hazelton Ave.,.P.O09 <br /> _. Box 20 , Stk., CA 95201 t <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT*NO. <br /> INFO <br /> ►.,\ ♦ EW 19-24(REV.1/H 5] / <br /> 1�- EH 11-28 !r,1� . - <br />