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APPLICATION FOR PERMIT <br /> `r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA d <br /> Telephone {209) 466-6781 4 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) l <br /> all the work herein <br /> , This <br /> cation is <br /> Application <br /> is heieby <br /> withde to San Joaquin San <br /> County OrdinauLn lnce No.549 for sewage or Health District for a permit <br /> 1862 for weiPpump atnd the Rules and Regulations of the San f Joaquin <br /> ma <br /> k Local Health District. <br /> Lot Size ! PM <br /> _] City <br /> 442 <br /> 4 Job Address <br /> Phone S <br /> Owner's Name Address <br /> 1 License No. p f1 � Phone <br />' Contractor $ Address <br /> TYPE OF WELL/PUMP: NEW WELL 11WELL REPLACEMENT ❑ DESTRUCTION LI <br /> Pl1MP INSTALLATION' --'-°"'SYSTEM REPAIR O --OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> r° DISPOSAL FLD. i PROP . LINE <br /> I FOUNDATION AGRICULTURE WELL^-' " ' OTHER WELL PITSISUMPS 111 <br /> �j��� 1T <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION.SPECIFICATIONS✓ pia. of Well Casing <br /> ❑ industrial ❑ Open Bottom - 171 Manteca Dia.-of-Well-Excavation--• <br /> i_ Specifications,—' " <br /> Domestic/Private <br /> ❑ Gravel Pack El Tracy Type of Casing <br /> l"I Public n Other F1 Delta Depth of Grout Seal i Type of Grout <br /> I 1 Irrigation �..Approx. Depth I I Eastern Sula a Seal Installed'-by <br /> H.P. // r"i'`r ' state Work Done <br /> I. Repair Work Done ❑ Type of Pump {yQ <br /> k Well Destruction ❑ Well Diameter Sealing Materibl Itop 50'1 *v <br /> " z <br /> J 09 <br /> Depth filler Material IS elow 50'1 °', - <br /> is stern <br /> ! TYPE OF SEPTIC WORK: NEW INSTALLATION I.1 REPAIRlADDITION lit DESTRUCTION l aveila�e'witliin 200 feet.) <br /> if public sewer is �, <br /> I nstallation will serve: Residence— Commercial_ Other <br /> er <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> ' SEPTIC TANK ❑ Type/Mfg _Capacity_ No.,Compartments <br /> -„�__� r <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well foundation Property Line <br /> 4 / i 3 <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size _ t <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> I <br /> 1 Number �'• , <br /> SEEPAGE PITS l I Depth Size — .� <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line r, <br /> DISPOSAL PONDS ❑ � <br /> will be done in accordance with San Joaquin county-ordinances, state laws, and <br /> I hereby certify that I have prepared this application and that the work <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 t all eq uir tions. Complete drawing on revs a side. <br /> X <br /> Signed _ <br /> Title: Date: <br /> FOR DEPARTMENT US ONLY <br /> ~ ; Area <br /> I Application Accepted by CS1 fr1� Date .,..� <br /> Pit or Grout Inspection by <br /> " �.. Final Inspection by Date�� <br /> h Additional Comments: Y ,.•� ;Cl'Trac 835-6385 <br /> Q Stk 466-6781 ❑ Lodi 369-3621 .a❑ Manteca 823-7104 Y <br /> Applicant - Return all copies to: Environmental Health Permit/Seryices 1601.,E._Hazelton_Ave_P.O.-Box 2009, Stk.,.CA.95201 <br /> FEEAMQUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> CASH <br /> +.EH 13-24 IREV.1111 51 INFO <br /> EH 14.20 - ` <br />