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APPLICATION FOR PERMIT <br /> LO SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466.6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a <br /> made H compliance with San Joaquin County Ordinance No.549 for sewageorNo. 1862 for it to cwell well/pump and the Rules and Regulaor install the work herein tions of the San l'Joaquin <br /> Local Health District. t <br /> Job Address 1 �°[�,� <br /> City �J C' 40vN Lot Size ac <br /> ��C�+`1(ll 5 KA C'S 6 h PM <br /> Owner's Name '?? �•��� <br /> Address 33 t ! <br /> Phone_MlJ <br /> Contractor's Name f <br /> TYPE OF WELL/PUMP: License No. <br /> NEW WELL ❑ WELL REPLACEMENT ❑ Phone ra <br /> PUMP INSTALLATION ❑ DESTRUCTION ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 5/ SYSTEM REPAIR X OTHER ❑�_ <br /> FOUNDATION <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> AGRICULTURE WELL <br /> INTENDED USE OTHER WELL PITS/SUMPS <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom �— <br /> ❑ Manteca Dia. of Well Excavation <br /> M Domestic/Private ❑ Gravel Pack ❑ Tracy T Dia. of Well Casing <br /> ❑ Public ❑ Other ❑ DYPe of Casing <br /> Delta of Grout Seal Specifications <br /> ❑ Irrigation Depth <br /> ---Approx. Deptstern Type of Grout <br /> Repair Work Done ❑ Type of Pump3�6 Surface Seal Installed by <br /> Well Destruction ❑ U Sealing <br /> P. r State Work Done ►�1 � d t .r p <br /> Well Diameter �_ Sealing Material (top 50') <br /> Depth r1.1 Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system <br /> Installation will serve: Residence_ Permitted if public sewer is <br /> Commercial_ available within 200 feet.) <br /> Number of livingunits: Other <br /> Number of bedrooms <br /> Character of soil to a depth of 3 feet: w 6 <br /> SEPTIC TANK ❑ Type/Mfg Water table depth <br /> PKG. TREATMENT PLT. ❑ Capacity___ No. Compartments <br /> Distance to nearest: Well Method of Disposal <br /> Foundation�_ Property Line <br /> LEACHING LINE ❑ No. &Length of lines <br /> FILTER BED ❑ Distance to nearest: WellTotal length/size <br /> Foundation� property Line <br /> SEEPAGE PITS ❑ Depth <br /> SUMPS Size :Number <br /> ❑ Distance to nearest: Well <br /> DISPOSAL PONDS ❑ Foundation__ property Line <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 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 <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 not <br /> tion laws of California." permit is issued,I shall employ persons subject to workman's co <br /> The applicant ust c II for all re ire inspections. Complete drawing on reverse side mF �^ <br /> Signed <br /> Title: 1 [Ce_ ` U5. /Z- <br /> Date: <br /> - 1 <br /> Application Accepted by A i"T-1 FOR DEPARTMENT USE ONLY <br /> Z- �--� +4 <br /> Pit or Grout Inspection by Date� Area_ 1 <br /> Date Final Inspection by <br /> Additional Comments: Date�s�/T <br /> Stk 466-6781 ❑ Lodi 369-3621 ❑ MXanteca 823-7104 <br /> plicant- Return all copies to: Environmental Health Permit/Services 1601 E.❑Hazel on Tracy Ave.� P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE <br /> INFO AMOUNT REMITTED CK RECEIVED BY DATE <br /> CASH PERMIT"NO. <br /> EH <br /> 3-24(REV.10/83) <br />:H 14-28 <br /> �� 1 <br />