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13: 00 <br /> APPLICATION FOR PERMIT <br /> ,Yr - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED ` <br /> (Complete in Triplicate) <br /> /of install the work herein <br /> . This <br /> cation is <br /> made inion is compliance with Sanothe Joaqu n County Ordinance uin llNo.549 for sewage or ealth District for a permit <br /> No. 1862 for welUpump and the Rules and Regulations of the San'Joaquin <br /> Local Health District. <br /> Li City Lot Size PM <br /> Job Address <br /> Address Phone. <br /> Owner's Name '• <br /> Contractor dress <br /> License No. <br /> Phone <br /> TYPE OF WELL PUM NEW WELL ❑ WELL REPLACEME ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES IDISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial LJ Open Bottom ❑ Manteca Dia. of Wel{ Excavation <br /> Dia. of Well Casing <br /> 0 Domestic/Private ❑ Gravel Pack ❑ Type of Casing g Specifications <br /> t"1 Public ❑ Other n Delta Depth of Grout Seal Type of Grout - <br /> k I Irrigation ,.Approx. Depth 1 I Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Sealing Material (to 50'1 i <br /> Well Destruction ❑ Well Diameter 9 p <br /> Depth Filler Material (Belo <br /> i <br />[ TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION IQFSTRUCTION [ I (No septic system permitted if public sewer is <br /> f i available within 200 feet-1 <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: —,V— Number of bedrooms Ir i <br /> ' Character of soil to a depth of 3 feet: Water table depth <br /> Capacity t No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg <br /> PKG. TREATMENT PLT. ❑ } Method of Disposal <br /> Distance to neatest: Well -Foundation I Property Line <br /> I <br /> �EACHI;111'41F� LINE ❑ No. & LengthoflinesTotal length/size <br /> FBED ❑ Distance to nearest: Well Foundation Property tine t� <br /> tti "v <br /> AGE �r I 1�.-Depth Size Number <br /> ' SUMPS ❑ Distance to nearest: Well�-J'�� Foundation� Property Line�_� <br /> DISPOSAL PONDS ❑ <br /> I 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, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant t c r req a nspections. Co late drawing an re s side. <br /> Signed X y Title: Date: - <br /> !' F DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by �` <br /> I Pit or Gr'oui Inspection by r. Date Final inspection by Data i {t <br /> . 6 <br /> Additional Comments:• <br /> ❑ Stk 466-6781 ❑ Lodi ' 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> FEE <br /> AMOUNT DUE AMOUNT REMITTED CASH RECEIVE[? BY /DATE PERMIT NO. <br /> s.EH 13-24(REV.I H5) INFO �'0 - .j �!24 <br /> EH 14-2a <br />