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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 v <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> made in ion <br /> compliance with Sanade to)aqu nthe SanCoungty Ordinance Joauin f { No.549 for sewage or ealth District for a permit <br /> Noo. 1862 for well/and/of <br /> mp and the Rules and herein <br /> R Regulations of the Sanapplication <br /> Joaquin <br /> Local Health District. <br /> !14 <br /> G � � CCIi! C J 7 G C _ Crty CG A�Jr��'��u"� Lot Size_ PM <br /> Job Address _. r <br /> Phone `�ai - _ 4 3 <br /> Owner's Name <br /> 1 1)�J' Address r} <br /> ConEractar L1 � LAa1LU1� Address 9)►) Lp 7!� G" License No. Y$�'��iJ -Phone%F 43°� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS E <br /> INTENDED USE TYPE OF WELL V PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca,,",, . Dia.-of-WellExcavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> FI Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation --Approx. Depth• I I Eastern Surface Seal Installed by State Work-Done-- <br /> Repair <br /> Work Dane ❑ Type of Pump % H.P. _ <br /> Well Destruction ❑ Well Diameter Sealing Material [top 50'1 °" <br /> 50'1 <br /> Filler Material (Below <br /> Depth - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION l (No septic system"permitted if public sewer is <br /> vailable within 200'feet.) ! <br /> Installation will serve: Residence_ Commercial— Other l <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> { - — Water table depth r <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ i Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ "No."& Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest:­- WCA—_ Foundation Property Cine <br /> l f f <br /> 1 SEEPAGE PITS I i Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Cl <br /> 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 compansa <br /> tion laws of California." <br /> f The applicant must call for all required " spections. Complete drawing on reverse side. <br /> Title: <br /> FOR <br /> fel 'n Date: <br /> r Signed X r <br /> FOR DEPARTMENT USE ONLY <br /> b <br /> � <br /> Applicatibn Accepted by. - Date Area �] <br /> Pit or Grout Inspection by Date Final Inspection by <br /> • Date 2? ! <br /> Additional Comments: ' <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ T cy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> /2 <br /> FEEAMOVNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> a.EH 13-24(REV, <br /> EH 14-2e <br />