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APPLICATION FOR PERMIT IVA <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA v <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Appt to <br /> t and/or install the work <br /> n describe .This <br /> cation is <br /> madlecnticompliance with SanoJoaqu the n County Ordinance n Joaquin lNo. 549 for sewage orHealth District for a 'No. 1862 for well//pump and the Rules and'ft gulations of he San'Joaquin <br /> Local Health District. a <br /> ,,,JJJ���iiiiii s �J City�� ot Size PM <br /> ' b Address �t �' <br /> �/S y lr�� Address j� l Phone ' <br /> Owner's Name 7 ���j- <br /> . O <br /> Address y License IVo. <br /> ContractorPhoneme"'�4A0 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> " ' # PUMP INSTALLATION 1-1SYSTEMREPAIR ❑ OTHER El <br /> DISTANCE TO NEAREST:.SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS , <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n <br /> Dia. of Weli Casin <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ,9 <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i .f <br /> '' <br /> f`I Public nOther U] Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation - —.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> z'Well Destruction ❑ Well Diameter Sealing Material (top 501 I <br /> !"k Depth <br /> Filler Material (Below 50') a <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONX REPAIRIADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> ti <br /> Installation will serve: Residence X Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Q� r <br /> Character of soil to a depth of 3 feet: � Water table depth. <br /> .rte <br /> A- capacity /"0 No. Compartments ' <br /> SEPTIC TANK EDType/Mfg p I • <br /> PKG. TREATMENT PLT. ❑ Method of Disposal_.i s <br /> Distance to nearest: Well 10-12Foundation 40 Property.LineS 712 <br /> LEACHING LINE No. & Length of lines Total length/size (Y1 <br /> FI TER BED ❑ Distance to nearest: WeU���_ Foundation I' Property Line - if t -ti <br /> SEEPAGE PITS Depth _Size N�u�mber <br /> SUMPS Cl Distance'to nearest:' Well Foundation�..�� Property Line !t7 t 3 <br /> DISPOS7 PONDS-0._.- <br /> h <br /> ONDS•---_❑. ,_ <br /> —. = r+ <br /> I hereby certify that I have prepared this application`and-chat--the work will be done in accordance with,San Joaquin county ordiriances, slate laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> �-:�„'" <br /> I Home owner or licensed agent's signature certifies the following. "I certify that in the performance of the woik for which this permit is"issued, I shall not <br /> i employ any person in such manner as to become subject to workman's compensation laws of California.;Contractors hiring or sub-contracting signature <br /> l certifies the following: "I certify that in the performance of the,work for which this permit is issued, I shall employ persons ubject to wofkman's compensaVIA <br /> - <br /> tion laws of Cali nia." ��'` . ,✓ st i ": <br /> The applic t t call all re uir in c' C mplete drawing on reverse side <br /> Signed X Title: <br />„ OR DEPARTMENT USE NLY <br /> �- <br /> Z <br /> Application Accepted by � Date <br /> P or Grout Inspection by Date � Final`Innspecctttiionn'by <br /> �� Date <br /> Additional Comments: <br /> r. iC rIGr r <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Me to:a -7104 ❑ Tracy 835-6385 ,( <br /> Applicant_ Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk CA 95201 <br /> FEE MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> *.EH1324IREV.1/Hs; �p-1t <br /> A EH 14-26. 1.J <br />