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APPLICATION FOR PERMIT <br /> SAN JOAQUI.N LOCAL HEALTH DISTRICT <br /> 1601 E. ELTON AI(E., STOCKTON, CA U <br /> i I Telephone {209]466-6781 y <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 4 <br /> (Complete in Triplicate) M <br /> r .�. . _ <br /> /or install the work <br /> n described.This <br /> Health <br /> t to <br /> Applications hereby ante with San Joaqu nnCounty ordinance Joaquin lNo.District549 for sewage or'No, 1862 foroweil/dpump and the Rules and(Regulations of the San'Joaquin <br /> made in compliance <br /> 'Local Health District. <br /> 'Lot Size PM <br /> City <br /> Job Address �7c! <br /> y � <br /> a r t �I <br /> Phone F! 7 <br /> Owner's Name <br /> Contractor - / <br /> ' Csi License No. Phone <br /> Address <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LJ DESTRUCTION EJ <br /> ER LINES — DISPOSAL FLD. OP. LINE <br /> DISTA E TO'NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL TSP <br /> SUMP <br /> FOUNDATION <br /> INT NDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pi f Well Casing <br /> EJ Indu ria) ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Sp ications ? <br /> ML Dom sticlPrivate ❑ Gravel Pack ❑Tracy Type of Casing <br /> Tyof Grout <br /> ❑ Publi [I Other 1-1DeltaDepth of Grout Seal <br /> p <br /> ❑ Irriga on _-4pprox. Depth ❑ Eastern Surface Seal Installed by 1 <br /> k <br /> P Repair ark Done ❑ Type of Pump <br /> H 3/ State Work Done <br /> Well De truction ❑- Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 i <br /> f TYPE 0 SEPTIC WORK: NEW I ALLATION ElREPAIR/ADDITION F1 DESTRUCTION ❑ available septic <br /> within 200 rmitted if public sewer is <br /> Install tion will serve: Residence Commercial— Other Q <br /> f Numb r of living units: Number of bedrooms Water table d <br /> Chara er of soil to a depth of 3 feet: No. Compart <br /> SEPTIC ANK ❑ Type/Mfg Capacity <br /> Method of Ai f r <br /> PKG. T ATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well Foundation <br /> i " <br /> LEACHI G LINEI] <br /> . _ No.& Length of lines Total length/size <br /> FILTER ED <br /> L1 Distance to nearest: - Well Foundation Property Line <br /> Size Number <br /> SEEPAG PITS ❑"Depth Pro rty Line <br /> 4 SUMPS El Distance to nearest: Well Foundation <br /> DISPOS L PONDS _ ❑ <br /> I hereby ertify that I have prepared thid that the work will be done in accord nee with S n Joaquin cou ty ordinances, state laws, and <br /> s application an -=T <br /> rules an regulations of the San Joaquin Local Health District. <br /> k Home a ner or licensed agent's signature eert+#i wi that in the perform nee of the ork for which his pefmit is issue I signa <br /> shall ture <br /> not <br /> employ a y person in such manner as to become subject to rk o ch this perm) ition laws o d,f�shall a ploy pe�sons's biect t wgrkman''s compensa- <br /> certifies a following:"I certify that in the performance of the ilW <br /> y <br /> -tion laws of California." . .. 4, <br /> The app) ant must c all required inspections. Complete drawing�on r erse side. <br /> ! <br /> Date: <br /> Signed _ rte: <br /> FOR D ARTMENT USE, ONLY q <br /> Date L Area <br /> 1 Application Accepted by, 4)�4� <br /> ` <br /> I , T, .,,;:,; ` Date Zf <br /> r Pit or Grout-inspection by <br /> Date Final Inspection by <br /> Additional Comments: <br /> ❑ Stk 466-6781 LI Lodi 369-3621 ❑ Manteca 823-7104 L3 Tracy 835-G365 <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 <br /> 0 RECEIVED BY DATE PERMIT'NO. <br /> LINIO+EH 1324(REV.t/B 5 <br /> EH 14-28 <br />