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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE-,-TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> iComplete in Triplicate) application is <br /> I <br /> App un Ordinance No.549 for sewage or No. 1882 for well/Pump and the Rules and Regulations of the S�Joaquin <br /> .cation is hereby made to the San Jooaquin Local Health District for a permit to construct and/or install the work herein described.This <br /> made in compliance with San Joaquin County 0 I �FY <br /> Local Health District. WT- ` r 6 <br /> 19 nvo- City ,C r n.d en Lot Size PM <br /> Job Address <br /> :74•/6O Cir For, 2�, Phone <br /> Address <br /> Owner's Name <br /> t 1.14 <br /> { -3 I,S - — Plibne <br /> i ll i erase No. <br /> Contractor's Name - r 4)ESTRUGTION-❑ " <br /> ,. <br /> NEWJ WELL REPLACEMENT-❑' �r .r <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ OTHER ❑ ,. ^ <br /> I PUMP INSTALLATION ❑ = ptSPOSAt FLD.190--'-PROP LINE .L`! <br /> e�� :� -5E1Ar•ER,i1NES� �� PUTS/SUMPS <br /> + DISTANCF-TO TANK AGRICULTURE WELL � OTHER WELL—FOUNDATION ?t 11 ' <br /> i INTENDED USE TYPE OF WELL PROSL� E� - CONSTRUCTION SP <br /> ECIFICAT ONS pia. of Well Casing o d <br /> Open Bottom ❑ Manteca Dia. of Well Excavation Specifications ►�"°Sa <br /> ❑ Industrial ` ' Type of Casing (� <br /> ❑ Tracy _� Type of Grout <br /> Domestic/Private- ❑ Gravel Pack Depth of Grout Seal <br /> ❑ Other ❑ Delta6. r <br /> I ❑ Public Surface Seal Installed by <br /> Irrigation <br /> ----Approx. Depth C1 Eastern State Work Done <br /> H.P. <br /> Repair Work Done 3 ❑ Type of Pump _ Sealing Material 501 <br /> Well Destruction ; ❑ Well Diame : ._._ <br /> i Depth Filler Material Blow 50'1 , , . <br /> tic system permitted if public sewer is <br /> available within 200 feet.? <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION ❑ o sep <br /> Other <br /> installation <br /> 4. Installation will serve: Residence— Commercial <br /> r Number of living units: Number of bedrooms Water table depth ' <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Foundation Property Line <br /> Distance to nearest: Well <br /> Total length)size <br /> LEACHING LINE ❑ No. & Length of lines Well Foundation Property Line y <br /> FILTER BED ❑ Distance to nearest: <br /> Number <br /> Size <br /> SEEPAGE PITS [j�Depth Pioperty Line <br /> SUMPS <br /> ❑ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS r� ❑. - i 0 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinartces,'state laws, and <br /> rules and regulations of the San Joaquin Local Health District. ` work for <br /> not <br /> Home owner or licensed agent's signature become s the following:o wn'srtcompensation lify that in the aws <br /> employ <br /> California."Contractor's hiring or su"ontract ngs permiti is issued, l signature <br /> employ any person in such manner a <br /> cart'rfies the following:"I certify that in the performance of the work for which this permit is issued,V shah employ persons subject to workman's compen - <br /> tion laws of California." <br /> The applicant u t call for all r ired inspections. Complete drawing on reverse ide. r J <br /> w_ .f w�l _ Date: <br /> Title: - <br /> signed �- <br /> FOR DEPARTMENT USE ONLY r r <br /> Date �J Area <br /> Application Accepted by � pate <br /> l <br /> [? date Final Inspection by <br /> Pit or Grout Inspection by _ <br /> ,. Additional Comments: ❑ Lodi 3W3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> ❑ Stk 466-6781 Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009 <br /> Applicant , Stk., CA 9520 <br /> CK RECEIVED By DATE PERMWND. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH t - _. -,— - -M- <br /> INFO <br /> +EH 13-241REV.101831 ,1:N • <br /> EH 1426 <br />