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rt APPLICATION FOR PERMIT <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) ligation is <br /> work herein <br /> Application is hereby ma Sano the Joaqu n County Ordinalncle No.549 for sewage or ealth District for a permit <br /> No. 1862 for construct <br /> eii/pump and the Rules and Regulations of This <br /> he San Joaquin <br /> made in compliance w <br /> ithLocal Health District. �. <br /> Lot Size PM <br /> 'iJob Address <br /> Phone <br /> A�'ddress <br /> �E3wner's Name <br /> / License No._�--Phone <br /> "7AContractor <br /> Address <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LJ <br /> TYPE OF WELLIPUMP: SYSTEM REPAIR 12OTHER ❑ <br /> PUMP INSTALLATION Ll <br /> SEWER LINES �._-- DISPOSAL FLD. POOP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK _ _� PITSISUMPS <br /> FOUNDATION AGRICULTURE' OTHER WELL <br /> 4 ' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia.-of•WeI.EkCavation <br /> ❑ Industrial Type of Casing Specifications <br /> 11 Domestic/Private ❑ Grave Trac <br /> Gravel Pack ❑ Y <br /> Depth of Grout Seal Type of Grout I x <br /> Cl Other <br /> 171 Delta <br /> M Public Surface Seal Installed by <br /> I I Irrigation —.Approx. Depth l 1 Eastern <br /> __ H P State.Wprk.Done., <br /> Repair Work Done ❑ Type of Pump Sealing Material (top 50'I <br /> Well Destruction ❑ Well Diameter <br /> Depth Filler Material iBelow 50'1 <br /> TYPE OF SEPTIC ORK: NEW INSTALLATION l 1 REPAIRlADDITION l i DESTRUCTION (No <br /> septic Permitted if public sewer is <br /> ailablew thin 200 feet.) <br /> h <br /> Oter <br /> installation will serve: Residence— Commercial. <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments <br /> SEPTIC TANK 171TypelMfg ` J �! Method of Disposal <br /> PKG, TREATMENT PLT, ❑ <br /> Distance to nearest: Well <br /> Foundation Property Line <br /> i <br /> Total length/size <br /> LEACHING LINE CI No- & Length of lines Property Line <br /> ❑ Distance to nearest: Well <br /> Foundation <br /> FILTER BED I <br /> Size Number <br /> I I Depth <br /> SEEPAGE PITSProperty <br /> SUMPS ❑ Distance to nearest: Well Foundation Line <br /> r 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, and <br /> rules and regulations of the San Joaquin Local Health D11trict. <br /> sed 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 /> Home owner or licensuch manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> employ any person in s <br /> f hich this permit is issued, I shall employ persons sybject to workman's compensa- <br /> certifies the following: certify that in the performance of the work for.w <br /> tion laws of California." { - - -- �- - __­i -- ' ' v <br /> The applicant must call for all required inspections. Complete afawing on reverse `side: 1f <br /> Date <br /> ®� <br /> Title: : <br /> Jz <br /> Signed )�- -- — v � .. <br /> FOR DEPARTMENT USE ONLY ,� r <br /> � � Date <br /> Date Area 1 <br /> Application Accepted by � 1 �U <br /> Pit or Grout Inspection by Date <br /> Final Inspection by - <br /> Additional Comments: <br /> ❑ Stk 466-6781 E) Lodi 369-3621 C] Manteca 823-7104 ❑ Tracy 835-M5 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> C RECEIVED By DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED SH <br /> INFO ��� 7 <br /> ♦.EH 13-24(REV.5/H 5) <br /> EH 1426 <br />