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J''3 <br /> APPLICATION FOR PERMIT ! <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 ISSU; DJ� <br /> I ' <br /> (Complete in Triplicate) >' <br /> q r , ''' "`' application is <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the wor. ind R descnbed. This <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin <br /> Local Health District ENVIRG.ME i T OIL HEALTH <br /> FERFAIT/SERVICES PM <br /> Q City, Lot 5rze <br /> Job Address fr �Y A <br /> Owner's Name <br /> r', Address Phone <br /> License IVo�is Z Phone <br /> Contractor �^�"'� Address 1JF <br /> TYPE OF,WELL/PUMP:. NEW WELL 15WELL REPLACEMENT ❑ DESTRUCTION LJ (� <br /> SYSTEM C REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION v <br /> DISTANCE TO NEAREST: SEPTIC TANK` y` SEWER LINES OTHER WELLL LD. PITS/SUMPS <br /> PROP. UNE <br />` FOUNDATION AGRICULTURE WELL OTHER W <br /> i Y INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ industrial ❑ Open Bottom Y❑ Manteca Dia. ai Well Excavation <br /> Specifications <br /> I- i�+pomestic/Private�� ❑ Gravel,Pack �� ❑ Tracy }'Type of Casing Type of Grout <br /> FI Public Cl Other k" Cl Delta Depth of Grout Seal — <br /> r �„ �[ <br /> I V Irrigation /.... . -Approx. Depth 1 I 1 astern Surface Seal Installed by <br /> i' �.�y(� State Work Done <br /> Repair-Work-Done LiK Type o(P <br /> um <br /> H-P; <br /> Well Destruction �+. Well Diameter Sealing Material [top 50'1 <br /> Depth ' ��w t Filler Material (Below 5U'i <br /> a <br /> :,TYPE OF SEPTIC WOR NEW INSTALLATION t 1 REPAIR/ADDITION (.1 DESTRUCTION I I {No septic system permitted it public sewer is <br /> available within 200 feet.] <br /> Installation will serve: Residence= Commercial's Other ,, <br /> Number of living units: Number of bedrooms ��i <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> + PKG. TREATMENT PLT. ❑ Method of Disposal <br /> k Distance to nearest: Well Foundation Property Line <br /> :LEACHING LINE _ ❑ No. & Length of lines Total length/size <br /> . 'FILTER BED j.❑ f Distance to nearest: ;,Well Foundation -Property Line <br /> + x�� . <br /> SEEPAGE PITS I 1 Depth ! �Size Number <br /> I <br /> SUMPS CIDistance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ", L] <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: "t 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 taws 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 /> Tho applicant u t ca for all requir inspections. omplete drawing on <br /> reverse side. ; / (J� <br /> Signed X le: Date: 1,(� ff, o <br /> F R DEPARTMENT USE ONLY <br /> 4 - Date `-'�'� Area �! <br /> Application Accepted by ' <br /> f Pit or Grout Inspection by Date," Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca 823-7104 El Tracy 835-6385 <br /> f Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE --T CK RECEIVED BY DATE PERMIT'NO, <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> + EH 13-24 IREV.1/R 51 <br /> EH 14-28 l� <br />