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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> it 1601 E. HAZEL T ON AVE., STOCKTON, CA <br />' Telephone (209) 466-6781 <br /> ;I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> i I (Complete inTriplicate) <br /> application is <br /> p o. 1862 for welllpump andd the Rules and Regulations of the San Joaquin <br /> Application is hereby made to the San Joaquin Local Health District for a ermit t°construct and/or Inst the work herein described. This <br /> made in compliance with San Jioaquin county Ordinance No.549 for sewage or N <br /> 14 Local Health District. <br /> f / ,? <br /> I� g r) City Lot Size PM <br /> Job Address <br /> 1-t- y` Phone l L ` <br /> Owner's Name <br /> ' �`1 l.1Ci1 1` Address ` <br /> A Address License No._�—_—.-Phone— <br /> Contractor <br /> O­FWE W 71ELLIPUMP: 4� NEWELL WELL REPLACEMENT ❑ DESTRUC <br /> TYPETION ❑ <br /> I} PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER F1I II SEWER,LINES DISPOSAL FLD. PROP. <br /> I� DISTANCE TO T:. SEP,TIC.TANK. <br /> r Ii F TION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> LEM AREA CONSTRUCTI ICATIONS� <br /> �i <br /> INTENDED USE TYPE OF WELL <br /> ❑ Open Bottom ❑ Manteca ell Excavation 'Dia. of Well Casing <br /> � <br /> [I Industrial , 1 Specifications <br /> ❑ Domestic/Private 0 Gravel Pack Type ° <br /> r I Delta M Public f(;Other <br /> f 1 Depth of Grout Sea Type of Grout -- <br /> I I Irrigation Approx. Depth 4 I Eastern Surface Seal Installed by F <br /> :i �. H p State Work Done <br /> Repair Wor e 11 Type of Pump <br /> EIestruction ❑ IlV1 Diameter Sealing Material (top 50'1 <br /> Filler Material (Below 50') <br /> _. <br /> Depth <br /> i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t l REPAIR/ADDITION I 1 DESTRUCTION' availablelc system within 200 feet.) it public sewer is <br /> d <br /> I� Installation will serve: Residence, Commercial, Other <br /> ' 11 Number of bedrooms <br /> l Number of living units: <br /> J Character of soil to a depth of 3 feet: 'Water table depth.„_. .�.- <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> 4 Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> I� <br /> ,I I Distance to nearest: Well Foundation Property Line <br /> N <br /> I � , l length/size <br /> ITota <br /> ' LEACHING LINE ❑ No. & Length of lines , <br /> } FILTER BED ❑ ' Distance to nearest: Well Foundation Property Line <br /> Number <br /> SEEPAGESEEPAGE PITS {'l Depth Size <br /> f SUMPS Ll' Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS' ❑ <br /> l <br /> 'I hereby certify that I haverepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> l rules and regulations of the(San Joaquin Local Health District. <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,l shall employ parsons to workman's compensa- <br /> subject 1 i <br /> i tion laws of California.' I� <br /> The applica ust call for re uir inspectio $. Complete,drawing on reverse side. <br /> Sined K Title: Date: F <br /> g lI r <br /> FOR DEPARTMENT USE ONLY �w <br /> Area <br /> oDate <br /> Application Accepted by Date <br /> Pit or Grout Inspection by <br /> Date Final Inspectin by <br /> , I . <br /> Additional Comments: - <br /> ❑ Stk 466-6781 ❑-Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 , <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY FDAEE PER MIY NO. <br /> INFO <br /> ,.EN 13-24 t1'1EV.1/n51 <br /> �- 3� f� — ' Ur gs <br /> .I EH 14-26 - <br />