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:j <br /> i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> 1� <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) application is <br /> permit to construct and/or install the work herein de <br /> Application is heretay made to the San Joaquin Local Health District for a scribed. This <br /> e or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for sewag <br /> Local Health District. PM <br /> 7�X dO <br /> Cr of Size j .�.� — <br /> I Job Address ` <br /> .. ne <br /> I Address <br /> Owner's Nam <br /> Contractor Address <br /> License No. "�Phone <br /> k TYPE OF WELL/PUMP: NEW WELL El WELL ❑ DESTRUCTION <br /> WELL REPLACQ <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. UNE <br /> DISTANCE TO NEAREST: SEPTIC TANK ELL PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL O <br /> ON SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONS pia. of Well Casing <br /> j ❑ Open Bottom ❑ Manteca ra. of Well Excavation <br /> ❑ Industrial Specifications' <br /> Type of Casing <br /> 0 Domestic I Private Q Gravel Pack Depth of Grout Seal Type of Grout <br /> [-i Public ❑ Other ❑ Delta _ <br /> [ <br /> pr x, Depth l 1 Eastern Surface Seal Installed by <br /> I I Irrigation State Work Done — <br /> 4 Type of Pump Seal <br /> r Repair Work Done Yp <br /> Well De ion ❑ Well Diameter Sealing Material trop 50'1, <br /> r Depth Filer Material (Below 50'1 <br /> r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [l REPT"IRIADDITIDN 1.1 DESTRUCTION i =ilabetrwthin 200 fec system et.) lF public sewer is <br /> Installation will serve: Residence Commercial— Other <br /> fNumber of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: Capacity_ <br /> ❑ Type/Mf <br /> Type/Mfg No. Compartments <br /> [ SEPTIC TANK Method of Disposal <br /> PKG. TREATMENT PLT. ❑ t Property line <br /> Distance to nearest: Well Foundation <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Property Line <br /> FILTER BED ❑ Distance to nearest: Well Foundation p Y <br /> I Depth Size Number <br /> SEEPAGE PITS Property Line <br /> SUMPS Ll Distance to nearest: Well Foundation <br /> 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 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 /> Theapplicant t call for all required i spections. Complete drawing on reverse side. / <br /> (Title: Date: <br /> Signed ` <br /> r FOR DEPARTMENT USE ONLY <br /> Date " Area r <br /> Application Accepted byDat <br /> r <br /> Pit or Grout Inspection by <br /> Date Final Inspection by <br /> i Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3 1 ❑ Manteca 823-7104 ❑ Tracy 835-6385 �'�i>''L <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., C�95201i9�� 1 f <br /> t <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'ND. <br /> t [NFO <br /> +.EH 13-24(REV,I/ s7 '�� V O C�� y <br /> {• EH 14-29 <br />