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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 TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is ; <br /> or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage <br /> Local Health District. <br /> City Lot Size PM � <br /> Job Address t Q <br /> Address 533 " Phone <br /> Owner's Name„ V V _ <br /> Phone3LI'� ©� <br /> Contract Address License No <br /> TYPE OF WELL/PUMP:- NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION (71 SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ; 1 <br /> v <br /> L3 Industrial ❑ Open Bottom LlManteca Dia. of Specifications <br /> Well Excavation Dia. f Well Casing <br /> - <br /> LJ Domestic/Private ❑ Gfavel Pack ❑ Tracy Type of Casing <br /> � <br /> 1-1;Public F1 Other Fl Delta Depth'of Grout Seal rt Type of Grout , <br /> I I Irrigation —,.Approx. Depth I 1 Eastern 4,_Surface Sealr installed by - <br /> H p 'State Work Done Q) <br /> Repair Work Done ❑ Type of Pump <br /> y <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 <br /> --.Depth--—- - - - _ --Filler-Material I Below-50'I• _- - -- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION W REPAIR/ADDITION i I DESTRUCTION l I INo septic system permitted if public sewer is <br /> (� y _ available within 200 feet.l r <br /> Installation will serve: Residence Commercial Others r <br /> Number of living units: Number of be ms <br /> Character of soil to a depth of 3 feet: " Watertable depth <br /> � 'rr <br /> SEPTIC TANK k—'—Type/Mf Capacity��,�-,� No. Compartments <br /> PKG, TREATMENT PLT. ❑ F 6 - Method of Dis?osal ro- <br /> EJ�i — <br /> Distance to nearest: Well � Foundation Property Line <br /> —, - - A <br /> LEACHING LINE & Length of lines d Total length/size <br /> + Foundation Property Line <br /> FILTER BED ❑ Distance to nearest: Well p y , <br /> SEEPAGE PITS IN' Depth _ �/ —Size . M``-�iVumber <br /> SUMPS ADO Foundation F ;'Property Line <br /> ❑ Distance to nearest: Well --�--�— <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and than tthe work`will be done HT accdrdance wR 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 follow_mg: "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+nrorkman'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 /> r,tion laws of California." <br /> The applicant call for t req red inspections. Complete drawing,on rev rs�side. <br /> Signed X. Title: : (//�� Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by,+'L Date Area ` <br /> --�/ � <br /> Pit or Grout Inspection by Da a Final Inspection by ate Z <br /> Additional Comments: ' <br /> ❑ Stk 466-6781 ❑ Lodi '369-3621 CI Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave:, P.O. Box 2009, Stk., CA 95201 <br /> !FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y OATE PERMIT•NO. <br /> ,l <br /> F + EH 3-24 <br /> EH 14.2818 .tx51 35;, <br />