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II 5 <br /> 's II <br /> '! APPLICATION FOR PERMIT t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR.FROM DATE ISSUED <br /> (Complete ink Triplicate) <br /> e work <br /> . This <br /> t andlor install th <br /> Application is compliance withade Sancation is <br /> oJoaquthe an countyn 11 ordinanceOrdinauin lnce No. 549 for sewage or permitHealth District for a to <br /> 1862 forconstrucwell/pump and the Runes and herein <br /> Regulations of he Safi Joaquin- a <br /> made in comp <br /> Local Health District. <br /> ,S'T �l,/ PM <br /> " f City Lot Size <br /> Job Address a <br /> Phone <br /> x� Address ✓� <br /> Owner's Name �� f�6f✓r/ <br /> Q �0 ✓�r� <br /> Address License No. Phone / <br /> Contractor /�0 <br /> WWELL REPLACEMENT ❑. DESTRUCTION ❑ <br /> TYPE OF FLL/PUMP: NEW WELL ❑ <br /> OTHER El <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL .PITS/SUMPS <br /> INTENDED USE T TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> El industrial d Open Bottom ❑ Manteca Dia.'of Well Excavation <br /> Type of Casing Specifications ., <br /> ❑ Domestic/Private ❑ Gravel(Pack ❑ Tracy Type of Grout - <br /> 1-1 Public n Other l=1 Delta Depth of Grout Seal <br /> I I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by <br /> 1 Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction L1Weli.Diameter r Sealing Material ifop <br /> Depth <br /> + ' er Material IBOJPW 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I'I EPAI ADDITION DESTRUCTION l I (Noavaseptic <br /> shin system Permitted ifjseweiis <br /> Installation will serve: Rest encu; CommercialOt�hte�r <br /> Number of living units: Number o drooms �b•�„, Water table depthCharacter of soil to a depth of 3 fee �-�- <br /> SEPTIC TANK ❑ Type/Mfg acity 49 4 No. CompartmentsMethod of Disposal <br /> F PKG. TREATMENT PLT. ❑ �4 '� ri ` k r <br /> .,..Distance to nearest: Wel! Q� Foundation .Property Gine <br /> 5€ <br /> LEACHING LINE ❑ No. & Length of lines I r Total length/size <br /> r~Cl <br /> FILTER BED ❑i Distance to nearest: Well - Foundation Property Line I <br /> SEEPAGE PITS. t•• l I Depth Size ? Number <br /> I SUMPS � ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> DISPOSAL PONDS ❑ v <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 /> r rules and regulations of the San Joaquin Local Health Di§trict. <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 shat{not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor'shiringosubject sub-contractworkman'iscompensa <br /> signatur J <br /> certifies the follopst <br /> : "I certify that in the performance of the work for which this permit is issued, I shall employ persons <br /> tion laws of Caliia." Ij <br /> The appli t call f all re s omplete drawing on verse side. <br /> Signed <br /> Title: Date: ~ - <br /> - I <br /> FOR DEPARTMENT USE ONLY <br /> it Area <br /> Application Accepted by k Date <br /> G}� Date <br /> Pit or Grout Inspection by Date Final Inspection by -I <br /> Additional Comments: <br /> (D; <br /> j ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 s ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2O<19, Stk., CA 95201 /n <br /> CK RECEIVED BY DATE PERMIT*NO. <br /> FEE <br /> INFO MOUNT DUE AMOUNT REMITTED CASH <br /> +.EH 13.24 1REV.1 <br /> EH 14-2a <br />