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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i ON AVE., STOCKTON, CA + <br /> ' Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �7 <br /> //� r� . r r , {Complete in Triplicate) ,it <br /> t� 1 <br /> Application is hereby made to the San Joaquin Local Health District far a permit to construct and/or install the work herein described.This application is r <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 Heal Istri t. <br /> Lel f- ,. lw Ll l�'� Lot Size�7 14# PM <br /> City <br /> Job Address <br /> `.w ,G M .if Phone 6 1 <br /> Owner's Name <br /> Address �Y <br /> Contractor 11 � Address <br /> "6 License No. Phone 4 t1 <br /> TYPE OF W1 LL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ <br /> "' ^'�'""SYSTEM f�EPAIR^L-1--' OTHER ❑ ! <br /> PUMP INSTALLATION f PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES ��--- DISPOSAL FLD. <br /> ` � PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHERi.WELL_2Xd-� <br /> INTENDED USE TYPE OF6. ELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> it <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> f l Dia. of Well Casing f+` <br /> Tracy Type of Casing I Specificati�rC�❑ DomesticlPrivate Gravel Pack DeltaDepth of Grout Seal Type of Gr <br /> F] Public i7 Other <br /> Appro I'. Depth l 1 Eastern Surface Seal installed by t DQ <br /> Irrigation I / H P State ork Done <br /> "Repair Work Done ❑ Type of Pump <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth = Filler Material IBelow 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l'1 REPAIR/ADDITION l I DESTRUCTION I I iallo.septicywithin m peretit�ed if public sewer is .. <br /> x <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> r Water table depth <br /> Character of soil to a depth of 3 feet: No- Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity—� <br /> - Method of Disposal = <br /> PKG. TREATMENT PLT. ❑ Property.Line <br /> Distance o nearest: We11 Foundation <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines 1Property Line <br /> FILTER BED ❑ • Distance jto nearest: well Foundation t <br /> ` Numbers <br /> SEEPAGE PITS C 1 Depth Size „ <br /> a <br /> SUMPS Cl Distance-to nearest: Well Foundation .Property Line C � <br /> DISPOSAL PONDS C7 <br /> ! hereby certify that I have prepared this application and that the work will be done iicordarcewith San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. 3 i _Y+ " <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 /> I employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following: "I certify that in the performance of the work for, hich�hispe permit is issued, I shall employ persons s cyto workm' cPens � <br /> _,_lion-laws-of-California. ' <br /> I The applicant must tail for all required pections. Com tete drawing on reverse si e. <br /> Signed X <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Date _ Area �G <br /> Application Accepted by <br /> k Pit or Grout Inspection by <br /> bate Final Inspection by Date <br /> i Additional Comments: <br /> El 5tk 466-6781 ❑ Lodi 369-3621 EJ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, 5ik., CA 95201 <br /> FEE <br /> ;CKE RECEIVED BY jD�A�HTFPERMIT'NO. <br /> INFOAMOUNT DUE AMOUNT REMITTED <br /> +.EH13-241REV.tiHs1 n � �� <br /> EH 14-28 <br />