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APPLICATION FOR_PERMIT i <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 /> (Complete in Triplicate) ; <br /> made to the San Joaquin Local Health District-for a permit to construct and/or install the work herein described. This-application is <br /> Application is heieby <br /> or No. 16&2 for welllpump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage <br /> Local Health District. <br /> I L Lot size r PM <br /> City <br /> Job Address <br /> Phone <br /> owner's Name�� �� Address i <br /> Contractor l` A 8ress <br /> TWELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP:.. NEW WELL.❑ SYSTEM REPAIR LIOTWER ❑ <br /> PUMP INSTALLATION Cl <br /> SEWER LINES DISPOSAL FLO. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITSISUMPS. <br /> FOUNDATIQ.N_ <br /> AGRICULTURE WELL __.. . .___ ------__ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> 11 Industrial <br /> Q Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ifictons <br /> - <br /> Type of Casing <br /> Specifications <br /> El Domestic/Private ❑ Gravel Pack ❑ Tracy Depth of Grout Seal Type of Grout <br /> n Public Cl Other+ F1 Delta _ <br /> _Approx. Depth I 1 Eastern 5urlace Seal Installed by <br /> I I Irrigation —_- . State Work Done— <br /> �- - " "`; <br /> Repair Work Done El Type-of Pump H.P. <br /> Well Destruction _jWell m <br /> —Diaeter -Qt Sealing Material flop 501 <br /> Depth Filler Material (Below 50'1 <br /> permitted if public sewer is <br /> RUCTION i I (No septic system ` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION i�ESf available within 200 feet.) <br /> Installation will sen+e: Residencemmercial— 'Other <br /> Number of living units: _. Number of bedrooms <br /> Wate table depth <br /> character of soil to'a de¢th of 3 feet:—✓ .� <br /> 115P of t — Capacity �Kl ompatYments <br /> SEPTIC TANK g Method of Disposal <br /> E PKG. TREATMENT PLT. ❑ ti <br /> I Distance to nearest- Well Foundation Property Li -_ — <br /> bTotal lengthi size <br /> LEACHING LINE OL_No. & Length of lines ro e <br /> f FILTER BED CDpert Distance to nearest: Well Foundation_��-_— Property Lin <br /> I � <br /> Size t Number <br /> SEEPAGE PITS l 1 Depth property Line <br /> I SUMPS CP 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 wit San Joaquin county ordinances, laws, and <br /> rules and regulations of the-San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies tfor which this permit is issued, I shall not <br /> he following: "I certify that in the performance of the work <br /> i �mptoy signaturei <br /> any person in such manner as to become subject to workman's compensation laws of Caled,I shall <br /> Contrapeosonslsub subject t wojig or rkman's <br /> ce?t les the foliowin� certify that in the parformance of the work for which this permit is issued, I shall employ p 1 f <br /> tion la a of California." L <br /> he applic u t call for It req 'red in ctio to drawing on r verse Si0o. <br /> I <br /> Title: <br /> Date: t� <br /> ,t= -Signe t ? <br /> k - f <br /> .�.rFOFI-DI=PART:MfNT_USE.ONLY�: �-� .T-9 <br /> r v : Date `TT 'Area ©� T <br /> Application Accepted by \11)11 ' y <br /> Date <br /> Final Inspeotion-by'l <br /> Date 101 <br /> Pit or Grout Inspection b .�- <br /> ` Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 7104 ❑"Tracy ;835 63$5 <br /> Applicant - Return all copies to: Environmental Health,Permit/Services 1601_E..-H azelton-Ave.,_P_.0.-Box.2009,..Stk.,-CA-95201:,- <br /> I FEEAMOUNT DUE -CK RECEIVED BY DATE PERMIY N0. <br /> AMOUNT REMITTED [ 7 <br /> INFO <br /> �' <br /> ♦ EH 13.24 It�EV.1/es 51 70 <br /> EH 14-2a <br />