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APPLICATION FOR PERMIT <br /> f. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> G 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 /> Applicaon ist and/or install the work <br /> n described. Thris <br /> cation is <br /> made nt'compliaerebynce wiitth San ade oJoaqu the n County O d nan Joaquin Localnce No.HealthD549 for sewage or permit <br /> 1862 for cwell/pump and the Rules and IR gulations of he San l Joaquin <br /> Local Health District. <br /> Job Address <br /> 5—� C �� 7�^ r City �� '> -ot Size 0� � PM <br /> Owner's Name <br /> ^� <br /> -L..— Address Phone <br /> _ <br /> Address License No. Phone <br /> Contractor <br /> TYPE OF WELL/PU NEW WELL 11 WELL REPLACEMENT El DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK <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 El Open Bottom El Manteca Dia. of Well Excavation <br /> Type of Casing Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy yp g Type of Grout <br /> ❑ Public El Other 11 Delta Depth of Grout Seal <br /> ElIrrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done El Type of Pump <br /> H p State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION F-1 REPAIR/ADDITION El DESTRUCTION alvailable�wi hin 200 feet.) <br /> itted if public sewer is <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: <br /> Capacity No. Compartments <br /> SEPTIC TANK ElType/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ 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 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 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 applican must call for all required inspections. Complete drawing on reverse side. <br /> �Signed X <br /> •: �? Title: E 's—vi.ob-s✓ Date: — <br /> FOR DEPARTMENT USE ONLY <br /> It- Date `T/6 / Area <br /> Application Accepted by , ✓ <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date <br /> Additional Commen <br /> c-- 0 p7 f oo <br /> ❑ Stk 466-6781 El Lodi 369- 1 ❑ M nteca 823-7104 El Tracy 835-6385 4 <br /> ermit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> Applicant- Return all copies to: Environmental Health P <br /> FEECK RECEIVED BY <br /> INFO DATE PERMIT NO. <br /> AMOUNT DUE AMOUNT REMITTED <br /> + EH 13-24(REV.1 i H 5) � 00 <br /> EH 14-26 <br />