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APPLICATION FOR PERMIT <br /> 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 /> t and/or install the <br /> rk <br /> . This <br /> Application is hereby made <br /> cation is <br /> h Sano <br /> oJoaqu nnCoungty Ordinalnce No.549 for sewage or Health District for a INo. 1862 for t to cwell/pump and the R les and IR gulations of the San'Joaquin <br /> made in compliance w <br /> Local Health District. <br /> City`}� Lot Size <br /> Job Address <br /> Phone <br /> Owner's Name r�1 a,�n Address <br /> Zd ss g�X License No. Phone l <br /> Contractor ''" <br /> TYPE OF WELL/PUMP: ��EWWELL ❑ WELL REPLACEMENT E] DESTRUCTION El <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER ElSEWE <br /> DISTANCE TO NEAREST: SEPTIC TANK A t <br /> ,v <br /> R LINES DISPOSAL FLD. `""__.._PROP:"LINE"".�__`. <br /> !\FOUNDATION AGRICULTURE WELL OTHER WELL ;` PITS/SUMPS �. <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 <br /> INTENDED USE Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca \�1C <br /> Dia. of Well Excavation Specifications— - <br /> Type of Casing <br /> El ❑ Gravel Pack ❑ Tracy Depth of Grout Seal Type of Grout — <br /> ❑ Other F1 Delta <br /> [-I Public <br /> Approx. Dippth I I Eastern Surface Seal Inst lied by <br /> I I Irrigation State Work Done _ <br /> Repair Work Done ❑ Type of Pump H.P. <br /> Sealing Material (top 50'1 <br /> Well Destruction El Well Diameter Filler Material (B 11 elow 50') <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALI{ATION REPAIR/ADDITION l 1 DESTRUCTION l 1 aNail`ebPelwt in 20c sYsts 0 permitted if public sewer is <br /> Installation will serve: Residence_ ommefd8r—`-Offibt <br /> Number of living units: -/-- Number of bedrooms — i <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> No: Compartments <br /> SEPTIC TANK ❑ Type/Mfg Qw �-�a'pC�'d�- � Capacity ��0�-- <br /> Method of Disposal <br /> PKG. TREATMENT PLT. L-1! <br /> r / <br /> Distance to nearest: Well /10 foundation /O — Property Line �O '� y <br /> Total lengtWsize' <br /> LEACHING LINE No. & Length of lines11 r <br /> FILTER BED ❑` Distance to nearest: Well <br /> Foundation Prop Orly <br /> �� Size Number <br /> Depth <br /> SEEPAGE PITS p4L '�- pro Line <br /> SUMPS Ll Distance to nearest: Well Foundation �2 Property, <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin-imunty-ordinances.-state laws, and <br /> rules and regulations of the San Joaquin Local Health District. �work for <br /> that in the Home owner or licensed agentas torbecome subject Ito worr'an s certify <br /> lawsoof Califonce n ahe'Contract r's1hir ng'or sub-contracting signature <br /> employemploy any person in such manner <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." 1 <br /> The applicantst all for all r uired i ctions. Complete drawing on rave side. <br /> i Title: Date <br /> Signed X <br /> r FOR,D PARfIM`ENT USE ONLY <br /> Date Area <br /> Application Accepted by n ' �'�Y <br /> Final Insplction by fate�sL <br /> Pit or Grout Inspection by Date r <br /> Additional Comments: <br /> El 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 /> CK RECEIVED BY DATE PERMIT'NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> + EH 13-24(REV.i i H 5) /20 <br /> EH 14-29 <br />