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'3 APPLICATION FOR PERMIT ._ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 r' <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate] <br /> all the <br /> rk <br /> n described. <br /> is <br /> cation is <br /> made in(compliance writh SanoJoaquin County Ordinance Nthe San Joauin Local o. 549 for sewage or h District for a permit <br /> 1862 for cwell/dpuomp end the Rues and 1ft Regulations of tlhe San l Joaquin <br /> Local Health District. <br /> Job Address <br /> y � S01 C CityMa12�c�l nt Size PM <br /> - 17 <br /> Owner's Name <br /> Address - Phon <br /> Contractor -�( �.�� Address License No. ,,�_ +,`,��Z .—Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSJE REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK r rib SEWER LINES © I DISPOSAL FLD. PROP. LINE <br /> FOUNDATION 5C) . AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC IONS t T <br /> 1:1Industrial ❑ Open Bottom 171Manteca Dia. of Well Excav, ion Dia. of Wel! Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I ! Public F1 Other ❑ Delta Depth at Grout Seal v Type of Grout <br /> I I Irrigation 1,3Z�!_.Approx. De th 1 I Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump I� t.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50') <br /> Depth 7k - Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTAL ATION I 1 REPAIR/ADDITION I I DESTRUCTION 1 I (No septic system permitted it public sewer is <br /> available within 200 feet.I <br /> Installation will serve: Residence_. Co ercial_ Other <br /> Number of living units: Number of be oms <br /> Character of soil to a depth of 3 feet: W epth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well _ Foundation Property Line <br /> LEACHING LINE ❑ No. & �.a,-.t <br /> Tota! length/size <br /> FILTER BED ❑ DistanWell undation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS L-I Distance to nearest: Well Foundatio Property Line <br /> DISPOSAL PONDS ❑ 1 <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, !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 applica us4 all for all re i din ctions. Complete drawing on reverse side. <br /> Signed X Title: ate: �r <br /> IF EPARTMENT USE ONLY <br /> Application Accepted by na,' Date Area - <br /> Pit or Grout Inspection by <br /> Date l Final Inspection by Date A 3— <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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> +.EH 13-24(REV,I I H 5) 1 Vts gs'�� <br /> EH 1♦-26 <br />