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EZ <br /> APPLICATION FOR PERMIT J <br /> y SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA `�C�3s� <br /> i <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED 1 <br /> (Complete in Triplicate) <br /> wrk here <br /> cation <br /> Application is hereby made to the San Jo uin Local Health District for pe or it o. 1862to torcwelllpumpond the is <br /> and/or install the Ruoles and(Regu <br /> PPlations of he Sanl Joaquin <br /> made in compliance with San Joaquin Countysewage OrdinanceNo.549 or g <br /> Local Health District. . <br /> City Lot Size PM <br /> Job Address + <br /> Phone <br /> Address Il - <br /> Owner's NameIF+ Q _ q <br /> a��� License No. �u Phone 0 <br /> Contract Address—,;2;25d <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCT( <br /> TYPE OF WELL/PUMP: M <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES —..---- <br /> DISPOSAL FLD. PROP. LINE ! <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Industrial , Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> Delta Depth o1 Grout Seal Type of Grout <br /> [`1 Public Cl Other � 9 _ <br /> Pp <br /> A roxi Depth l i Eastern Surface Seal Installed by <br /> k 1 Irrigation — iState Work Done _ <br /> Repair Work Done ❑ Type of Pump H.P. <br /> ' Sealing Material (top 50'.),. <br /> Well Destruction ❑ Well Oiamet*r <br /> Depth � Filler Material 18eiow 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION l 1 DESTRUCTION l avaao ilablelwithin 200 feet.)permitted if public sewer is , <br /> Installation will serve: Residence��� Commercial— Other 0 <br /> I Number of bedrooms l <br /> Number of living units: , Water table depth <br /> Character of soil to a depth of 3 meet. . . Compartments <br /> r -- SEPTIC TANK ElType/Mfg <br /> 1� Capacity <br /> �. Method of Disposal <br /> i PKG. TREATMENT PLT. ❑ :1 Line } <br />_ <br /> Distance.to nearest: Well Foundation i Property <br /> fTotal length/size— <br /> LEACHING <br /> ength/size LEACHING LINE � No. & Length of lines Property Line <br /> FILTER BED [DDistance to nearest: Well Foundation P rh' <br /> Size Number <br /> SEEPAGE PITS I t 'Depth ' property Line <br /> SUMPS [I Distance to nearest: Wel! Foundation <br /> DISPOSAL PONDS L] k. <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 /> Homo 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 signature <br /> shall not <br /> ring or sub <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contracolsubj ct to orkman Is gcompensa- <br /> E certifies the following:"I Certify that in�the performance of the work for which this permit is issued, k shall employ persons <br /> tion laws of California." <br /> The app4muLcallquired inspections. Complete drawing reverse: de. Q Title: Date: <br /> Signed , <br /> FOR TMENT USE ONLY `D <br /> /Date Area o <br /> Application Accepted^by <br /> Date Final inspection by <br /> Date a o2 <br /> � Pit or Grout Inspection by <br /> Additional Comments: �1_ <br /> f ElStk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-M51601 <br /> t 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> Applicant- Return all copies to: Environmental Health Permit/Services <br /> ff3m1w!9 <br /> CK RECEIVED BY DATE PERMIT'NO. <br /> CASH / <br /> + EH 13-24 IREV.i/e sl <br /> FH U-26 . <br />