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—' APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEILTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 ,. <br /> PERMIT EXPIRES 1 YEAR FROM 'DATE'ISSUED' <br /> (Complete in Triplicate) W <br /> or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Application is hereby made to the San Joaquin Local Health District for sewagerape to construct and/or install the work herein described.,This application is <br /> pP hence with San Joaquin County ordinance 4 <br /> made in comp' <br /> Local Health District. f,l, <br /> Lot Size PM <br /> Job Address <br /> 14_ CitY., <br /> Phone <br /> Address <br /> ' <br /> Owners Name <br /> v License No. Phone <br /> Address DESTRUCTION ❑ <br /> Contractor WELL REPLACEMENT ❑ <br /> TYPE OF WELLIPUMP: NEW WELL ❑ OTHER ❑ <br /> SYSTEM REPAIR Ll PROP. LINE <br /> PUMP INSTALLATION� <br /> DISTANCE TO NEAREST: SEPTIC TANK DISPOSAL FLD. <br /> SEWER LINES �— PITS/SUMPS <br /> AGRICULTURE WELL OTHER WELL <br /> FOUNDATION /— <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> ❑ Industrial ❑ Tracy Type of Casing <br /> ❑ Domestic/Private ❑ Gravel Pack Type of Grout <br /> ❑ Other ❑ Delta Depth of Grout Seal <br /> )(Public Surface Seal Installed by <br /> '❑`Irrigation _--Approx. Depth El Eastern �' State Work Done <br /> Type of Pump <br /> Repair Work Done ❑ Sealing Material (top 50'1 <br /> j Well.Destruction ❑ Well Diameter Filler Material {Below 50'1 <br /> i 4� <br /> Depth I <br /> i available within 200 feet.) 0J <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if pub is sewer is r <br /> Installation will serve: Residence Commercial— Other l— <br /> " <br /> Number of living units: Number of bedrooms Water table depth <br /> i Character of soil to a depth of 3 feet: Capacity� No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal i <br /> PKG. TREATMENT PLT. ❑ Foundation— Property Line <br /> Distance to nearest: Well fill <br /> Total length/size <br /> LEACHING LINE ❑ " No. & Length of lines Property Line / <br /> FILTER BED ❑ Distance to nearest: Well <br /> Foundation <br /> Size Number 0 <br /> SEEPAGE PITS ❑ Depth Property Line Foundation�� .. <br /> SUMPS ❑ Distance to nearest: <br /> Well <br /> _ <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, an <br /> rules and regulations of the San Joaquin Local Health District. I. <br /> to workman's compensation laws of California." Contractor's hiring or tow sub-contracting <br /> ntrac'seomnature <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 <br /> pensa- <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject <br /> tion laws of California." ' _ <br /> The applicant must for all rlequir d inspections. Complete drawing on reverse side. <br /> Dat: <br /> _ f Title: <br /> Signed <br /> FOR DEPARTMENT USE ONLY 9 � <br /> ��r _ Date Area <br /> Application Accepted by <br /> Date—�- Final Inspection by <br /> Pit or Grout Inspection by . <br /> Additional Comments: T ❑ Tracy 835-6385 Stk., CA 95201 <br /> 0 Stk 466-6781 ❑ Lodi 369 3621 ❑ Manteca 823-7104 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009 <br /> CK RECEIVED BY DATE PERMIT`N0. <br /> ! FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO 4112). <br /> .+ EH 13-24(REV. <br /> EH 54-26 . ... .. - <br />