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APPLICATION FOR PERMIT <br /> �S <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ! <br /> 1601 E. HAZELiON AVE., STOCKTON, CA I� <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate)erm !,cation is i <br /> Application is heteb wmh Sano the Jvaqu Joaquin Qty Ordinance No. 549 for sewage orocal Health District for a p 'No 1862 forcwell/dpuomp and the Rules and hereindescribed. <br /> of he San Joaquin <br /> i <br /> made in compliance- <br /> Local Health District. r <br /> ?d City <br /> Lot Size PM <br /> Job Address <br /> —� � Phone <br /> Address <br /> Owner's Name <br /> License No. Phone <br /> Contractor_ - Address <br /> YPE OF WE <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> 4SYSTEM REPAIR, _.z.-, OTHER-0 <br /> PUMP INSTALLATION ❑ SEWER LINES PlT51SUMPS <br /> �� D1SP05 PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL HER WELL <br /> FOUNDATION <br /> RUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA Dia. of Wel Excavation Dia. of Well Casing <br /> ❑ Industrial El Open Bottom ElMante .. .- Specifications <br /> racy Type of Casing <br /> [I Domestic/Private ❑ Gravel Pack Depth of Grout Seat <br /> Type of Grout - <br /> 17 Other <br /> F] Delta <br /> i-1 Public Surface Seal installed by Q <br /> 1 1 Irrigation .-Approx. Depth l I Eastern <br /> Type of Pump H.P. <br /> estruction ❑ Well Diameter State Work Done _ <br /> Repair Work ❑ r Sealing Material Itop 501 <br /> Depth ' Filler Material [Below 501 <br /> rRo TYPE OF SEPTIC WORK: 14 E`1 XLATION i I REPAIR1ADDITIQN l l ' DESTRUCTION availabpelwi within 200 feet't)ed if public sewer is <br /> installation will serve: Residence <br /> Commercial -Other <br /> Number of living units: _Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK ❑ Type/M19 Capacity— <br /> iT Method_ of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> M Tata) length/size <br /> LEACHING LINE ❑ No. 8, Length of lines Property tine <br /> FILTER BED ❑, Distance to nearest: Well Foundation pe y <br /> f I 1 Depth Size Number <br /> I SEEPAGE PITS pa Line <br /> SUMPS L1 Distance to nearest: Well Foundation Pro <br /> DISPOSAL PONDS ❑ <br /> 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 Heaith District. <br /> l Home owner or licensed agent's signature certifies the following: "l certify that in the performance of the work for which this permit is issued, I shall not <br /> i <br /> employ any person in such manner as to become subject to workman's compensation laws of California." ploy cersonsrsub ct to workmanring or 'scompensa- <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ p 1 <br /> { tion laws of California." <br /> I <br /> The applic t ust call for all required-inspections. Complete drawing on reverse side. <br /> Title: <br /> -Date: <br /> �igned X <br /> FOR DEPARTMENT USE ONLY <br /> { Final Inspection by Date —Z'-Z Date <br /> Area <br /> Application Accepted by 7� I <br /> r Pit or Grout inspection by Date <br /> + <br /> i <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, S*., CA 95201 <br /> C ED BY DATE PERMIT'NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED ASR RECEIV <br /> INFO <br /> + EH 13-24(REV.t/n 51 <br /> EH 14-26 <br />