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E <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CAdl,,,�, <br /> Telephone (209) 466.6781 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED 04L <br /> (Complete in Triplicate)Appll � <br /> ade <br /> Joaquin <br /> ocal <br /> h District for a <br /> made <br /> int'on is compliance wiby th Sano the Joaquin nComy Ordinancle Nto. 549 for sewageeor't to No. 1862 forot and/or well/Pump and the Rules and Regulationrk herein s of the San'Joaquis <br /> Local Health District, <br /> Job Address <br /> Cit*- <br /> it )tf Lot Size PM <br /> Owner's Name Address�41Z-1913 <br /> _ Phone <br /> Contractor ��L �'� Address <br /> License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SY TEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULT E WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROSL AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industria! ❑ Open Bottom ❑ Mantec Dia. of Well Excavation <br /> ❑ Domestic/Private ❑ Gravel Pack Dia. of Casing <br /> ❑ Tracy Type of Casing S ecificalioations <br /> M Public ❑ Other p <br /> ❑ Delta Depth of Grout Sea! Type of Grout <br /> I I Irrigation .,_Approx. Depth I 1 Easter Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H P - <br /> State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filter Material (Below 50'I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i 1 DESTRUCTION t (No septic system permitted if public sewer is <br /> Installation will serve: Residence_ Commercial— Other available within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANKWater table depth <br /> ❑ Type/Mfg Capacity <br /> PKG. TREATMENT PLT. ❑ No. Compartments <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines <br /> FILTER BED ElDistance to nearest: Well Foundation Total length/size <br /> Property Line <br /> SEEPAGE PITS 1 ) Depth Size <br /> Number <br /> SUMPS D Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ _ Property Line <br /> 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. 1 <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 <br /> _ w permit is issued,laws of California." !shop employ y persons subject to workman's compensa- <br /> The applimomplete drawing on reverse side. <br /> Signed X Title: ~ <br /> Date: <br /> -1:-V— <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Q <br /> Area <br /> Pit or Grout Inspection Data Final Inspection by 6 t�X <br /> Date 4� <br /> Additional Comments: `lL f <br /> ❑ Stk 466-6781 Lodi 369-3621 Cl Mante 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 CK <br /> INFO /fes CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 1324 IREV.I/n 51 3 <br /> r/+-' l � <br /> EH 11-2e Q{� �� <br />