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APPLICATION FOR PERMIT <br /> 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 /> r (Complete in Triplicate) <br /> d <br /> Application is hereby made to the San CJoaquin ounty ordinance lHealth No.District549 for sewage or permit <br /> No. 1862 for we I/pump and the Rules and R gulations application of he SanJoaquin <br /> made In compliance with San Joaquin <br /> Local Health District. " <br /> sCity Lot Size PM <br /> �I <br /> Job Address _ - <br /> --' Phone <br /> - -" Address <br /> Owner's Name <br /> Phone <br /> " r License No. �REpL Contractar's Name WELCEMENT ❑ DESTflUCTkON ❑ <br /> TYPE OF WELL/PUMP: NEW ELL ❑ OTHER ❑ <br />` PUMP INSTALLATION ID DISPOSAL <br /> REPAIR El <br /> SEWER LINES �—• DISPOSAL FLD. ' i PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS <br /> FOUNDATION _�� AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIF1CATlONS pia. of Well Casing <br /> Dia. of Well Excavation i "r <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Specifications <br /> ❑ Tracy Type of Casing <br /> [3 Domestic/Private ❑ Gravel Pack ❑ Delta <br /> Depth of Grout Seal Type of Grout <br /> ❑ Public [3 Other � <br /> __JApprox. Depth ❑ Eastern Surface Seal Installed by <br /> ❑ Irrigation °" t State Work Done' <br /> Repair Work Done ❑ Type of Pump Healing Material )top 501 <br /> Well Destruction ❑ Well Diameter Filler Material {Below 50} <br /> Depth <br /> w* available within 200 feet.) <br /> TYPE IC NEW INSTA <br /> WORK: LLATION ❑ REPAIR/ADDITION LJ DEST <br /> YPE OF SERUCTION } [No septic system permitted if public sewer Is <br /> f installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of sail to a depth of 3 feet: Capacity- <br /> SEPTIC <br /> No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Foundation_�� Property Line <br /> Distance to nearest: Well , s <br /> ' Total length/size <br /> LEACHING LINE ❑ No. & Length of lines nearest: Well Foundation property Line <br /> ❑ Distance to <br /> FILTER BED <br /> Size --Number- <br /> SEEPAGE PITS ❑ Depth <br /> ` <br /> SUMPS ❑ -Distance to nearest:- Well <br /> Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an <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 sha not <br /> n :"I certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- <br /> n laws of California."Contractors hiring or sub-contracting signature <br /> employ any person in such manner as to-become subject to workman's.00mpensatio <br /> certifies the follow) g t ' <br /> tion laws of California." w <br /> The applica 11 r all required ins ctions. Comp1 to drawing on reverse side. <br /> Date: <br /> Signed <br /> FOR DEPARTMENT USE ONLY R <br /> } Date �' Area <br /> Application Accepted by Date <br /> Pit or Grout Inspection by <br /> Date�� Final inspection by <br /> I Additional Comments: 11Tracy 835-6385 <br /> [I Stk 466-6781 ❑ Lodi 369-3621 C] Manteca 823-7104 <br /> all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> Applicant -Ml <br /> RECEIVED BY DATE PERMIVNO. <br /> FEE. AMOUNT DUE AMOUNT REMITTED <br /> INFO Sb y <br /> +E1141344(REV.10/831 <br /> . EH W28 <br />