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� 3 <br /> APPLICATION-FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (208) 466-6781 ;:,Y. ' <br /> PERMIT, EXPIRES 1 YEAR FROM DATE ISSUED . . ' " ; <br /> �;..., .(Complete in Triplicate) <br /> scr' <br /> Application is hereby made to the San Joa�uinO�d Ordinance Not.District549 for sewage or permit <br /> No. 1 B62 for well/pump and the flulles and!Regulatior6i'on Is <br /> eis of the SanTHs'appll Joaquin <br /> made in compliance with San Joaquin County <br /> Local Health District. <br /> olg <br /> z w city Gs1,r Lot Size PM _ <br /> Job Address <br /> . -_ ��� ,.�,...:. —•�_ -,-:=� �� - PhonekPIC <br /> Owner's Name Address <br /> i Phone <br /> License No. <br /> Contractor's Name _ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION L3 <br /> I PUMP INSTALLATION <br /> SYSTEM'REPAIR L3 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> � SEWER LINES DISPOSAL FLD. PROP. LINE <br /> , <br /> FOUNDATION AGRICULTURE WELL OTHER WELL— <br /> INTENDED <br /> ( INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> ! ❑ Open Bottom ❑ Manteca Dia. of Well Excavation—_�--— <br /> ❑ Industrial Specifications <br /> ❑ Tracy Type of Casing_ �_ - _ <br /> ❑ Domestic/Private :1 Gravel Pack o Grcu <br /> _.w �•. .- �. Type f t , <br /> -- ❑ Other— " ❑-.Dilta Depth of Grout`Seim •, <br /> ❑ Irrigation_ ._ —�pprox. Depth Eastern-.� --.S�ace-Sed0 Public <br /> led by - f 5 <br /> H P State Work Done <br /> Repair Work Done Ll Type of Pump j <br /> Well Destruction ❑ Well Diameter — - <br /> Sealing Material (top 501 t <br /> Depth t Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ availableNo septic <br /> wi within 200 feet.),ill if-public sewer is. <br /> _ Installation will serve: . Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms Water.table depth <br /> Character of soil to a depth of 3 feet: 'ments <br /> Capacity # No.,CamRart <br /> t SEPTIC TANK ❑ Type/Mfg Method of;Disposal' <br /> t <br /> PKG. TREATMENT PLT. ❑ s ✓ i t_ <br /> r `t Property Line <br /> � Distance to nearest: Well Foundation _; i � �-•� <br /> Total length/size A <br /> LEACHING LINE ❑ No. & Length of lines M <br /> Foundation ` Property Line P <br /> k FILTER BED Ll Distance to nearest: Well _ r •:y <br /> �..� <br /> �- Number � "r <br /> SEEPAGE PITS ❑ Depth Size wf; <br /> Well � <br /> Foundation—-1 Property Line <br /> SUMPS ""'r El Distance to nearest: t <br /> DISPOSAL PONDS ❑ <br /> 1 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 /> t <br /> rules and regulations of the San Joaquin Local Health District. <br /> shall not <br /> Home owner orrlilice used h manner tarbeeome subject Ito workman'sng: rtcompensation Iify that in the laws of California." Contractor's lhi hiring or subcontracting lsignature <br /> employ Y Pe <br /> certifies the following:"1 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 .st call for all r ired{j1s ions. Complete drawing on raver side. — <br /> �y1 c � Date: <br /> Title: <br /> Signed n�y:,•,-� : <br /> FOR DEPARTM NT USE ONLY <br /> Date �G"z ��� .d?� :�•� <br /> Application Accepted by <br /> Final Inspection by r <br /> Date j <br /> Pit or Grout Inspection by <br /> Additional Comments: i <br /> ❑ Stk 466-6781 <br /> El 369-3621 ❑ Manteca 823-7104 ❑ Tracy a`t, <br /> I Applicant Return all copies to: Environmental Health Permitl5enricas 1601 E. Hazelton Ave., P.O. Box 2009,,Stk., GA 952fl7`'F.u.., <br /> CK :PER,MIT.'NO. <br /> FEE - -AMOUNT DUE. AMOUNT REMITTED CASH RECEIVED 9Y DATE T, <br /> INFO _ }U ;_.a . _4. �. <br /> +EH 1324IREV.101831 <br /> EH 14.26 �• Op _. - <br />