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-- APPLICATION FOR PERMIT 9 <br /> SAN JOAQUIN' LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL—1 ON AVE.. STOCKTON, CA <br /> Telephone.(209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) application is <br /> for sewage or No. 1862 for we and the Rules and Regulations of the San Joaquin <br /> Application is hereby made to the San Joa in Local Health District for a permit to construct andlor install the work herein described.This app <br /> made in compliance with San Joaquin County Ordinance N I <br /> Local Health District. i2�j 2,O PM <br /> �a W <br /> City—S_ O Lot Size <br /> Job Address r 3 1 <br /> Phone <br /> Address <br /> Owner's Name - ] <br /> RQ3$3 Ph ne p <br /> i y� <br /> License-No:- DESTRUCTION V r <br /> Contractor's-Name a NEW W L WELL REPLACEMENT <br /> TYPE OF WELL/PUMP: ; SYSTEM REPAIR�❑� C_ <br /> PUMP INSTALLATION Q � PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LINES° DISP05AL FLD. f <br /> FOUNDATION- ` AGRICULTURE WELL <br /> OTHER WELD— PITSISUMPS �� C <br /> � f< <br /> l INTENDED USE TYPE OF WELL <br /> PROBLEM CONSTRUCTION SPECIFICATIONS Dia I f Well Casing <br /> I Dia.`:of Well Excavation 1 Specifications <br /> I ❑ Industrial pen Bottom ❑ Manteca : ���� <br /> ` ikF❑ Tracy Type of Casing - raen <br /> ❑ Gp <br /> r_ayel Pack l Ty e�of Grou <br /> ,.Domestic/Private t <br /> ❑,ether r❑ Delta Depth of Grout Seal <br /> ❑ Public - +-'»may Surface Seal Installed by <br /> El Irrigation ��pprox. Depth ❑ Eastern State Work Done <br /> ' H.P. ii <br /> Repair Work Done *❑ TYPe of Pump �• <br /> Sealing Material {top 50'1 i <br /> i Well Destruction Well Di2�nater Filler Material (Below 50') <br /> E , Depth - ' <br /> YF available within 200 feet.) <br /> TYPE OF SEPTIC WORK:- NEW INSTALLATION ❑ REPAIRIADDlTION ❑ DESTRUCTION EJ [No septic system permitted if public sewer+s <br /> installation <br /> Other <br /> will serve: Residence Com <br /> �— <br /> 4Number of living units: } Number of bedrooms Water table depth <br /> Character of soil to a depth"of 3 feet: No. Compartments <br /> k Capacity r <br /> f SEPTIC TANK EI 'Type/Mfg Method of Disposal <br /> w <br /> i PKG. TREATMENT PLT. ❑ Property Line <br /> i Distance to nearest: Well <br /> Foundation <br /> ri <br /> I Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Foundation Property Line <br /> FILTER BED ❑ Distance' <br /> to nearest: Well <br /> 1 Size Number <br /> SEEPAGE PITS ❑ Depth Property Line <br /> SUMPS ❑ Distance to nearest: Well <br /> Foundation�� <br /> te laws, and <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that l have prepared this application and that the work will be done in accordance witthe work for which this permit is issued, 1 shall not <br /> rules and regulations of the San Joaquin Local Health District. <br /> j Home owner or licensed agent's signature certifies the following: "I certify that a the performance of <br /> signature <br /> employ any person in such manner as thbeC me subje <br /> cect of�he work for which this pe mi tion laws <br /> issued1f�hall employ persons lsubj subject t workman'soeompensa- <br /> certifies the following:"I certify that In pe <br /> tion laws of California." - <br /> The applicant mu call for all required inspections. Complete drawing on reverse side. Date: b� <br /> Title: <br /> Signed <br /> FOR DEP RTMENT 135E ONLY <br /> r Area <br /> Date 3 <br /> Application Accepted by incl Inspection by Date <br /> Pit or Grout Inspection by All <br /> Date <br /> Ad Tonal Comments: ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 2009, Stk., CA 95201 <br /> Stk 4664781 <br /> Environmental Hea <br /> Ap 'cant- Return all copies to: lth Permit/services 1601 E: Hazelton Ave., P.O. Box <br /> DATE PERMIT'NO. <br /> CK# RECEIVED BY <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH �u <br /> INFO iv 3 31!O V � 7� <br /> f+ EH 13-24(REV.101831 0s - - <br />