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APPLICATION FOR PERMIT <br /> _ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES T YEAR FROM DATE ISSUED" t <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora,permit to construct andlor install the work herein described. This application is <br /> made in compliance with San Joaquin Couwage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> nty Ordinance No.549 for se ' <br /> Local Health District. r: <br /> PM <br /> City <br /> City Lot Size " <br /> Job Address <br /> + Address 9 PhonerF <br /> Owners Name ;�_-^-"'� <br /> �Iddfess License N . <br /> Phone ✓ v <br /> Contractor <br /> TYPE OF WELL/PUMP: NEW WELL 1-1WELLREPLACEMENT El DESTRUCTION LJ i <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ L OTHER El <br /> SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST:.SEPTIC TANK <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J <br /> 11 Industria! El Open Bottom © Manteca Dia. of Well Excavation pia. of <br /> Well Casing <br /> Type of Casing Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Grout—_____=7 - <br /> ❑ Other P Delta Depth of Grout Seal <br /> f'1 Public ` � <br /> I I Irrigation _:.Approx. Depth " l I Eastern Surface Seal Installed by <br /> H p " r+P--- State Work Done <br /> Repair Work Done ❑ Type of Pump <br /> Well Destruction C] Well Diameter . Sealing Materia! (top 50'1 <br /> Depth Filler Material i8elow 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR ADDITION L1 DESTRUCTION I 1 (No se tic system availabe'wthin 200 feetit}ed if public sewer is 1 <br /> Installation will serve: Residence L Commercial Other } <br /> Number of living units: 1 Number of bedrooms <br /> Water table depth <br /> �! Character of soil to a depth of 3 feet: No. Compartments A <br /> J SEPTIC TANK ❑ Type/Mfg rGapacity � - <br /> i y; z I Method of Disp sal <br /> PKC. TREATMENT PLT. ❑ rl _ St V - <br /> Distance to nearesf: Well f-- Foundation Property Line <br /> i <br /> Total length/size n <br /> F`tLTER <br /> G LINE ❑ No. & Length of lines �— <br /> ❑ Distance to nearest: Well Foundation . - Property Line <br /> ED _ y <br /> COO 4 <br /> SEEPAGE PITS l 1 Depth �� _ Number <br /> UMPS Cl Distance to nearest: Well 'Foundation Property Line <br /> DISPOSAL PONDS ❑ . <br /> I rk will be done in accordance with San Joaquin counIy ordinances, state laws, and <br /> I hereby certify that I have prepared this application and that the wo <br /> rules and regulations of the San Joaquin Local Health District.. r <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 to workman's compensation laws 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 /> lion laws of California." <br /> The applicant u t call 11 r ired ins. tiio s. CompI a drawing on rev LSO side• <br /> - w� Hitler Date: <br /> Signed X n <br /> WOR'DEPARTMENT USE ONLYP��s r <br /> Dates' ` ' Area <br /> Application Accepted by - <br /> Inspection by Date Final Final Inspection by <br /> 1i1 _/r^ Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. eax 2009, Stk., CA 95201 <br /> FEE CK RECEIVED BY DATE PERMIT'NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CA H .41 <br /> #.EH 13-2 4(REV.s/H 51 <br /> EH 14-26 <br />