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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 4 YEAR FROM DATE ISSUED '.'. <br /> (Complete in Triplicate)onstruct <br /> t, rk <br /> cation is <br /> Health <br /> t to c <br /> Applicationam liance with Sanothe San Joaquin Joaqu'n County 0 dinalnce No.District549 for sewage or'No 1862 for well pump aor tnd the Ryles and Regulations of he San all the wo herein described.THs l Joaquin <br /> made in c p w e 'f JU4 <br /> Local Health District. <br /> !.� fT L l r PM .. <br /> t ( . vm V e I �* r: City". ?< I�= �'' Lot Size 1 <br /> Job Address "t <br /> Owner's Name � � ` <br /> Address Phone <br /> ContractorAddress <br /> License No.�XiPhone <br /> TYPE OF WELLIiz��M : ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION F] SYSTEM REPAIR ❑. OTHER LJ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ,, Specifications <br /> Type of Casing <br /> L3 Domestic/Private E Gravel Pack p Tracy Depth of Grout Seal Type of Grout <br /> El Public D Other C1 Delta P # <br /> ❑ Irrigation �pprox. Depth ❑ Eastern Surface Seal Installed by <br /> H p , State Woik;Done— <br /> Repair Work Done ❑ Type of Pump <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50;)_ <br /> (No,f TYPE OF Ssm <br /> EPTIC WORK: NEIN INSTALLATION V, REPAIR/ADDITION ❑ 'DES RUCTION availablelwthin 200 fe tatted if public sewer is <br /> UI <br /> Installation will serve: Residence— Commercial, Other <br /> Number of living units: Number of bedrooms f <br /> +. Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> Capacity 1 <br /> SEPTIC TANK ❑ Type/Mfg Method.bf Disposal <br /> PKG. TREATMENT PLT. ❑ Pro'e " -Line <br /> Distance to nearest: Well Foundation p rtY <br /> r —"Total"1e'�h/size- v <br /> " LEACHING LINE ❑ No. & Length of lines <br /> Property Line <br /> FILTER BE f r❑ Distance to nearest: Well Foundation P Y <br /> X�d <br /> Number _ <br /> ` SEEPAGE PITS ❑• Depth Size V <br /> 4 Foundation `' Property-Line <br /> SUMPS El Distance to nearest: Well e <br /> � 1 <br /> I DISPOSAL PONDS ❑ P <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 /> l 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 /> k pensation laws of California."Contractor s hiring or sub contracting signature <br /> employ any person in such manner as to become subject to workman's corn <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 Isvrs of California." <br /> The applicant must I fort l re wired inspections. Complete drawing r verse <br /> %'12 Title: f D I 7 <br /> Signed i <br /> FOR DEPARTMENT USE ONLY O <br /> r <br /> i Date Area <br /> Application Accepted by <br /> Flit or Grout'Inspection by =Date--_ <br /> Final Inspection-by— ----Date - - <br /> Additional Comments: <br /> F-1 Stk A66-B781 ❑ Lodi 369-3621 O Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Haalth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., GA 95201 <br /> i RECEIVED BY DATE PERMIT'NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> 1NFo <br /> 1F c9 ' 1]� 1�1 <br /> + EK 13-241REV,1/951 01 <br /> EH 1428 <br />