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a <br /> ., APPLICATION FOR PERMIT <br /> k <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> aii the work <br /> n describe . Tis <br /> Application is fiance with Sanis <br /> oJoaqu nncoungty ordinaJoauin lHealth District for a pnce No.549 for sewage or'No, 1862 forcwell/dpump aermt to construt an /or tnd the Rules and IR gulations of hhe San <br /> l cation Joaquin <br /> made in comp <br /> Local Health District. <br /> Cit Lot Size PM <br /> Job Address. <br /> r _fir_ Phone <br /> Address f <br /> Owner's Nam <br /> ( Contract Address d <br /> �3��L icense No, <br /> Phone �� <br /> I TYPE OF WELL/PUMP: NEW WELL *WELL.REPLACEMENT ❑ DESTRUCTION ❑ <br /> f OTHER E3LIPUMP INSTALLATION SYSTEM REPAIR <br /> ` <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> y INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> .Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> Fl Delta Depth of Grout Seal Type of Grout' —­ <br /> FI <br /> i`l Public ❑ Other "g <br /> Approx. Depth I Eastern Surface Seal Installed by ,- <br /> ) Irrigation r <br /> Type of PumpH.P."��'� State Work Done <br /> j Repair Work Done � yP -` <br /> Well Destruction ❑ Well DiameterSeafing Material (top 50'1 <br /> Depth Filler Material IBelow 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I ! DESTRUCTION i I availabs.le within 200 feetc system .) <br /> Installation <br /> if public sewer is <br /> l � Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms Water{'table depth y <br /> r Character of soil to a depth of 3 feet: <br /> Capacity J No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg - <br /> fVlethod of. <br /> I PKG. TREATMENT PLT. ❑ + ' .. <br /> I Distance to nearest: Well Foundation Property r� "` <br /> Total length/size— <br /> LEACHING <br /> engthlsize t <br /> LEACHING LINE El No. & Length of lines Al 111 2�0 gp� <br /> FILTER BED L1 Distance to nearest: Well Foundation Property Lin D <br /> I SEEPAGE PITS l i. Depth Size-t, Number �T� ,�✓ <br /> i ^: -' .} <br /> _ " FoundationPro a Lin � iC�0 <br /> Well <br /> SUMPS Cl Distance to nearest: <br /> I DISPO5AL PONDS— ❑ <br /> w 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 compensa- <br /> tion laws of California." ' <br /> The applicant must c f r all required it spections. Complete drawing on reverse side. <br /> r <br /> Signed X Title: Date: <br /> _ <br /> FA DEP ENT USE ONLY <br /> Date r Area �J <br /> Application Accepted by <br /> Fit or Grout Inspection by <br /> Data Final Inspection by ate tgl <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 E3 Manteca 823 7104 El 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 `--,CK RECEIVED BY DATE PERMIT'NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED ,CASH <br /> i.EH 13-24 TREY.iin51 �VD C( <br /> EH 14-26 ✓✓ <br /> r <br />