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/� APPLICATION FOR PERMIT <br /> 2A ✓ � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED QCT 1 ,11989 <br /> (Complete in Triplicate) ribed.This application is <br /> and/or install the work herein I ti ns of the San Joaquin <br /> Application is hereby made to the San Joaquin rd ordcal inance No.549 for sewage or ealth District for a permit <br /> 1862 for we l/pump and the Rule �Is NM HEALTH <br /> pp PERMQlM&CES <br /> made in compliance with San Joaquin County O <br /> Local Health District. PM <br /> City Lot Size <br /> Job Address �i /'". j one �j�16 i�.2�'d►sQ� <br /> a �^r h <br /> '��`' Addres <br /> Owner' ame Phone 5' <br /> �^ License No. <br /> AddressDESTRUCTION Elctor <br /> ContraWELL REPLACEMENT ❑ <br /> NEW WELL ❑ OTHER ❑ <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR El PUMP INSTALLATION J�SEWER LINES ----- DISPOSAL FLD. PITS/SUMPS PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK -- AGRICULTURE WELL OTHER WELL <br /> FOUNDATION ----- <br /> TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> INTENDED USE <br /> ❑ Open Bottom El Manteca Dia. of Well Excavation Specifications <br /> El Industrial racy Type of Casing _ <br /> ❑ Gravel Pack Type of Grout <br /> omestic/Private n Delta Depth of Grout Seal _ <br /> [`l Public n Other <br /> Surface Seal Installed by � <br /> I I Irrigation Approx. Depth l,/1 Eastern '� _ State Work Don <br /> Type of Pump X49444—_ H.P. <br /> Repair Work Done ❑ Sealing Material (top 501 <br /> Well Destruction ❑ Well Diameter - Filler Material (Below 501 <br /> Depth <br /> available within 200 feet.) <br /> TYPE OF SEPTIC WORK:. NEW INSTALLATION l flEPA1R/ADDITION L l DESTRUCTION l 1 (No septic system permitted if public sewer i <br /> Installation will serve: Residence — <br /> Commercial Other--- <br /> Number of living units: <br /> Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: Capacity__-_----- No. Compartments <br /> SEPTIC-TANK ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT.❑ Foundation._---- Property Line_–-- <br /> Distance to nearest: Well <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Foundation Property Line_----- <br /> FILTER BED ❑ Distance to nearest: Well <br /> _ Number <br /> SEEPAGE PITS Foundation------ <br /> I I Depth Size Property Line_----- <br /> SUMPS Ll Distance to nearest: Well <br /> DISPOSAL PONDS ❑ <br /> b certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an <br /> I hereby performance of the work for which this permit is issued, I shall not <br /> rules and regulations of the San Joaquin Local Health District. I certify that in the pe <br /> Home owner or licensed agent's signature certifies the following:' <br /> m to any p of the work for which this permit is issued,I shall employ persons subject to workman's compensa <br /> e arson in such manner as to become subject to workman's compensation laws,of California.' Contractor's hiring or sub-contracting signature <br /> p y I certify that in the performance certifies the following:" <br /> tion laws of California." �� <br /> The applicant must call for all required inspections. Complete drawing on reverse side. Date- <br /> Title: <br /> Signed X <br /> OR DEPARTMENT USE ONLY <br /> Date ff Area <br /> Application Accepted by Date <br /> Pit or Grout Inspection by <br /> Date-----.Final Inspection by <br /> Additional Comments: El nodi 369-3621 C3 Manteca 823-7104 ❑ Tracy 835-6385 Stk., CA 95201 <br /> ❑ Stk 466-6781 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2 , <br /> CASH RECEIVED BY <br /> DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO <br /> + EH 13-24(REV.ti Hal ✓ L wV — <br /> EH 14-28 <br />