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I <br /> �O APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> t and/or install the work <br /> tion is <br /> made in compliance with Sano the Joaqu nn Joaquin County Ordinancealth No.District 549 for serwage o,t to No.1862 forcwel(/pump and the Rules and herein described. <br /> of This <br /> rhe San'Joaquin <br /> made i <br /> Local Health District. <br /> `/ � ���7`� City�rPy Lot Size PM <br /> Job Address — T++�� // d <br /> � /�r Address 7 del� Phone <br /> Owners Name 76M <br /> "INF f!1 [' �����J Phone/y 7 �7 License No. <br /> Contractor's Name DESTRUCTIONTYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑SYSTEM REPAIR ❑ OTHER ❑PUMP INSTALLATION'SSEWER LINES DISPOSAL FLD. PROP. <br /> -- DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> Domestic/Private 11 Gravel Pack 11 Tracy Type of Cesin <br /> ❑ Public ❑ Other <br /> ❑ Delta <br /> Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ——Approx. Depth ❑ Eastern Syrface Seal Installed by <br /> H P ` State Work Done <br /> Repair Work Done ❑ Type of Pump <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') S <br /> Depth Filler Material (Below 50') Q <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ available'withne200 feet.) if public sewer is 6- <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms � <br /> 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. ❑ property Line <br /> Distance to nearest: Well Foundation <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Property Line <br /> FILTER BED <br /> ❑ Distance to nearest: Well Foundation <br /> SEEPAGE PITS ❑ Depth <br /> Size Number <br /> SUMPS ❑ Distance to nearest: Well <br /> Foundation Property Line <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, an <br /> rules and regulations of the San Joaquin Local Health District• work for <br /> Home owner or licensed agent'ssignature ecertifies <br /> o es the following:o w "I cen'srtify <br /> the <br /> hensation lawst in the oof Cal'ifornarmance of ."Contractor's hiring or sub-contracting signature <br /> employ any person permit La issued,I shall employ persons subject to workman's compensa- <br /> certifies the following:"I certify that in the performance of the work for which this pe <br /> tion laws of California." <br /> The applicant m I for it inaps S. C plete drawing;n�� <br /> Date: <br /> Signed Title: <br /> OR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by ,�] <br /> Date <br /> Final Inspection by , ' r DatePit or Grout Inspection by <br /> Addition0l Comments.: ,:.u.�'• <br /> ❑ Stk 466 8781;.::.i. '� i 383621 ❑ Manteca 823-7104 ❑Tracy 8356385 <br /> -Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9'x201 <br /> !CK RECEIVED 9Y DATE PERMITNO. <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO <br /> to• <br /> .EH 13241REV.'10/831 <br /> EH 1426 <br />