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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> 1601 E. HAZELT ON AVE., STOCKTON, CA <br /> Telephone (2091 466-6781 `"`'` '' <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> /or install the work <br /> n de <br /> cation is <br /> Application is hereby made to the San Joaquin Local Hlth District for a No.549 for sewage o INoo 1862 forcwellldpump and the R les and IR gulations of This <br /> San Joaquin <br /> made in compliance with San Joaquin County ordinance <br /> Local Health District. <br /> ►>t�_ Lot Size PM <br /> ` City <br /> Job Address *sre <br /> t "fi s' ff Phone <br /> Address (� !� <br /> Owner's Name ('�°` 1� <br /> (f/ I / License No. Phane <br /> Contractor tr Addres - <br /> WELL REPLACEMENT ❑ DESTRUCTION_^rr�' <br /> TYPE OF WELLlPUMP: NEW WELL ❑ SYSTEM REPAIR ❑ 'OTHER ❑ <br /> PUMP INSTALLATION ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK _OTHER WELL - PITS/SUMPS w <br /> _ -FOUNDATION AGRICULTURE-WEAL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> ❑ Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation Specifications <br /> EI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> 6 C� Delta Depth of Grout Seal Type of Grout <br /> r h] Public L1 Other _ <br /> Irrigation __Approx. Depth ! I Eastern Surface Seal Installed by <br /> ( t H.P. State W Done <br /> 11 I Repair Work Done ❑ Type of Pump __��-- <br /> 1 Well Destruction Well Diameter Sealing Material (top 50'1 <br /> Depth_��n Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION {:I REP ON l 1 DESTRUCT N I i avlailableseptic <br /> wthin 200 feet.) if public sewer is <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms Water table depth l� <br /> Character of soil to a depth of 3 feet: No. Compartments l.d <br /> SEPTIC TANK ❑" Type/Mfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> r Distance to nearest: Well <br /> Foundation Property Line <br /> Total length/size <br /> LEACHING LINE ❑. No. & Length of lines Property Line <br /> k FILTER BED . , ❑ Distance to nearest: Well Foundation p y <br /> r <br /> Size Number <br /> ' SEEPAGE PITS l 1 �-Depth Property Line <br /> I w- <br /> SUMPS <br /> ❑; Distance to nearest: Well Foundation <br /> d <br /> DISPOSAL-PONDS C7. r <br /> � 1 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 District. <br /> Home owner or licensed agent's signature certifies the following: "1 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 /> tion laws of California." <br /> The applicant must CAR for all required inspections. Complete drawing on reverse ide. � [1 <br /> r <br /> Title:4 Date: <br /> r t Signed X <br /> FO EPARTMENT USE ONLY <br /> Date l ___a�Area <br /> Application Accepted bV4 <br /> Date Final Inspection by � �• _ _- •Date- <br /> , Pit or Grout Inspection by - <br /> Additional Comments: <br /> E3 Stk 466-6781 D Lodi 369 3621 Manteca 823 7104 ❑ Tracy 635 6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601.E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CK RECEIVED BY DATE PERMIT NO. <br /> ffR!= CASH ^* <br /> + EH 13-24 TREY.I/a51 <br /> EH 1426 <br />