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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> 1� Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> t and/or <br /> all the work <br /> . This <br /> made in compliance fiance made <br /> th Sano the Joaqu nncounguin ty ordinalHealth District for a nce No.549 for sewage or permit <br /> No 1862 forcwell//pump and the Rules and IR Regulations of the Sancation is <br /> Joaquin <br /> made P <br /> Local Health District. <br /> ��� City ^""` ` Lot Size � PM <br /> Job Address <br /> Owner's Name � � ��"� <br /> Address Phone <br /> ' �f-73Gp 6 Phone � 6! Sao <br /> Contractor <br /> Address License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑_ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _— <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> El Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation <br /> Type of Casing Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack El Tracy Type of Grout ---- <br /> I`1 Public n Other [71 Delta Depth of Grout Seal <br /> I I Irrigation __..Approx. Depth I I Eastern Surface Seal Installed by <br /> H P State Work Done <br /> Repair Work Done Ll Type of Pump <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 — <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION (Nailabptic system <br /> m rented if public sewer is r� <br /> Installation will serve: Residence X_ Commercial_ Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK ElType/Mfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line i <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size _ Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 Di'Mrict. <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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applic nt ust ca , all required 'nspe ions. Complete drawing on reverse side. <br /> Signed X <br /> Title: 4i�%% � Date: <br /> FOR DEPARTMENT USE ONLY <br /> Date /V r Area <br /> Application Accepted by 1 <br /> Date Final Inspection by Date f <br /> Pit or Grout Inspection by <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 CK RECEIVED BY DATE PERMIT'NO. <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> ♦ EH 13-24(REV.t/H 5) <br /> EH 14-26 <br />