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I <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 ���czt f(� <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED g 1 -7 <br /> If <br /> (Complete in Triplicate) work <br /> here <br /> n described. This <br /> nstall the <br /> Application is hereby ith Sancation is <br /> oJoaquin County 0 dinalnce No.Health549 for-sewage or INo. 1862 forcwell/pumlp and the Rules and'Regulations of he San Joaquin <br /> made in compliance w <br /> Local Health District. I r S- 4 <br /> City r1 Lot Size <br /> k Job Address , 1 <br /> n1J t. Address : `'I C' ' Phone <br /> Owner's Name y-5 Y <br /> 0OLicense No. 1 ( Phone79a <br /> Contractor's Name <br /> ': <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION <br /> .SYSTEM REPAIR Q OTHER El6() '- SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK !S�-t—I.,AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> FOUNDATION <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑.Industdalti. ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ��" - Type of Casing Specifications <br /> ❑ Domestic/Private Q Gravel Pack ❑ Tracy - Type of Grout <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal <br /> ---Approx. Depth -Eastern „--- Surface Seal Installed-by — }� <br /> r <br /> El Irrigation �Pp ,.a- <br /> : <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter ___ Sealing-Material (top 5()')'-- .- <br /> Depth _-� .Filler_Material.lBelow 501 <br /> 'I� PE OF SEPTIC WOR NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION,1D (No sepeiws within 200 feetpe'mi.) public sewer.is <br /> Installation willrye:..-Residence 1' Commercial "'Other- �f <br /> Number of living units:-- Numb`er of bedrooms '_ + �� <br /> Water table depth �c <br /> Character of soil to a depth of 3 feet: No. Compartments / <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> * . Method of Disposal <br /> PKG. TREATMENT PLT. ❑ /C)() Foundation property Line <br /> Distance to nearest: Well/L1(- Foundation <br /> 1 Total length/size <br /> LEACHING LINE C3 . <br /> No.'& Length of lines Property Line <br /> f FILTER BED El Distance to nearest: Well Foundation <br /> t *� <br /> _Size� � - �`- Number <br /> SEEPAGE PITS ❑ Depth - property Line <br /> SUMPS ❑ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ <br /> l 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 /> I rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: '9 certify that it the performance of the work for which this permit is issued, I shall not <br /> l employ any person in such mangler as to become subject to workman's compensation laws ss California-" ploy Persons subject to wng or contracting signature <br /> orkman's ompensa <br /> certifies the following:"I certify.that in the performance of the work for which this permit is issued,1 shall employ pe 1 <br /> r <br /> 'tion laws of`California." <br /> Thea icant {ust call fog all required ' spections. Complete drawing on reverse side. <br /> Title: <br /> Date: <br /> Signed <br /> FO EPARTMENT USE ONLY <br /> Date �" Area <br /> Application Accepted by r �. <br /> Pit or Grout Inspection by <br /> 'Date •' 'Final Inspection by� Date <br /> 6itional Comments: <br /> Stk 466-6781 ElLodi 3643621 anteca 823-7104 ❑ Tracy 835-5365 <br /> !Applicant-'Return all copies to: Environmental ealth ermit/Services 1601 E. Hazelton Ave., P.O. 'Box 2009, Stk., CA 95201 <br /> FEE CK* <br /> RECEIVED BY DATE PERMIT'NO. <br /> � INFO AMOUNT DUE AMOUNT REMITTED <br /> t EH 13-24(REV.101531 �!' - • ( CS .-�L/ 1 �•• <br /> EH 1426 - -- <br />