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F f�` APPLICATION FOR PERMIT <br /> I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> .� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is he+eby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> I made.in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welu pump and the Rules and Regulations of the San Joaquin <br /> r. Local Health District. <br /> �City � Lot Size PM <br /> Job Address <br /> D Owner's Name ddress Phone <br /> Contractor <br /> /C! dress v? Uicense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> ' PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ 7 I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES " DISPOSAL FLD� PROP. LINE <br /> FOUNDATION ��� AGRICULTURE WELL — OTHER WELL -_�PITS/SUMPS f <br /> INTENDED USE TYPE OF WELL—�x PROBLEM AREA *CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial IJ Open Bottom IJ Malltec''a - Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ravel Pack ❑ Tracy Type of Casing fi Specifications <br /> i`l Public Cl Other _ Ll Delta Depth of Grout Seal, Tye of Grout , <br /> k <br /> Approx.-Depth -1 ('Eastern t� S ace Seal Installed - <br /> k I I Irrigation- - —� � '�/� y� � <br /> Repair Work Done ❑ Type of Pump H•P- /I state Work Done <br /> l � . 4 P K�j��_• <br /> Well Destruction ❑ Well Diameter Sealing Mate ial'itop 50'► <br /> Depth Filler Material IBelow 50'1 f — <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION 11 DESTRUC_TION-t-1_(No septic'system-'permitted if public sewer is <br /> m tet. available within'200 feet.) 9J <br /> Ir stallation will serve: Residence Commercial_ Other <br /> #• �_ Number of living units: Number of bedrooms y <br /> " � Water table depth <br /> Character of soil to a depth of 3 feet: v , _ <br /> SEPTIC TANK ❑ Type/Mfg Capacity " "` No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line - , <br /> LEACHING LINE ❑ No. & Length of lines L Total length/size ° <br /> r FILTER BED ❑ Distance to nearest: Well Foundation' 4 Property Line <br /> w <br /> 4 SEEPAGE PITS 11 Depth Size' — Number <br /> 1` SUMPS T[Ti"Dis6nce to nearest: Well Foundation Property Line <br /> a DISPOSAL PONDS ❑ . <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 DiMrict. <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, t shall not <br /> employ any person in such manner as to become subject to workman's compensation taws 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 ust r squire i ons. Compleettteef drawing onrevgua side. <br /> i, Date: <br /> Signed <br /> FO DEPARTMENT USE LY r <br /> Application Accepted by ' Date Area <br /> j v I Final Inspection by� Date� p <br /> Pit or+Inspection by Date <br /> I` Additional Comments: <br /> t ❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 635-6385 <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] C SH RECEIVED BY DATE PERMIT"NO. <br /> INFO <br /> ♦ EH 1324(REV,i i n 51 rj�_ ., ft <br /> °° �— l3 fLt- <br /> � ?�EH 14-28 C/ V <br />