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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (200) 466-6781 } <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> works p application is <br /> t and/or install the <br /> Application is hereby <br /> N th San Joaquin San <br /> Cooaquin Local Health unty Ordinance <br /> No.District549 for sewage or fNo-1862 forcwell Ipump and he Rules and Regulations of the San Joaquin <br /> made in compliance <br /> ' Local Health District. > <br /> Lot Size D PM <br /> gad <br /> City <br /> Job Address _ ,:: / �` <br /> Phone 5,,+ <br /> �1r amu`'—Address <br /> Owner's Name _ - <br /> �;/J Q License No01 ��"°` Phone <br /> Contractor 7`(� Address <br /> NEW WELL ❑ WELL REPLACEMENT IJDESTRUCTION ❑ <br /> TYPE OF WELLIPUMP: SYSTEM REPAIR ❑ OTHER ❑ <br />! PUMP INSTALLATION ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES — 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 /> F ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> �n Industrial 0 Tracy Type of Casing Specifications <br /> [3 Domestic/ ❑ Gravel Pack El Depth of Grout Seal Type of Grout <br /> El Public Q Other �- <br /> a Surface Seal Installed by ; <br /> r ❑ Irrigation w' __—Approx. Depth u ❑ Eastern $ <br /> H P State Work Done <br /> Repair Work Done ❑ Type of Pump i Sealing Material (top 50') <br /> Well Destruction ❑ Well Diameter �.� l <br /> Depth Filler Material (Below 50'1 <br /> ` TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ aNailabpelwthm 200 feet§ijed'rf public sewer is <br /> Installation will serve: Residence Commercial— Other <br /> Number of liv004 <br /> ing units: � Number of roams Water table depth <br /> l Character of soil to a depth of 3 feet:. 2- <br /> SEPTIC TANK ❑ Type/Mfg <br /> a r Capacity�� No. Compartments r <br /> Method of Dispa�1 <br /> PKG. TREATMENT PLT. ❑ f Property Line <br /> Distance to nearest: Well foundation i <br /> f ./� ` Total length/size <br /> LEACHING LINE No. & Length of lines f <br /> ❑ Distance to nearest: Well f O- Foun <br /> dation� Property Line <br /> FILTER SED .e� <br /> �/ ize umber *� <br /> SEEPAGE PITS Tr Depth Line <br /> 1 *W 1 Foundation_� — Property <br /> SUMPS El Distance to nearest: y Well <br /> DISPOSAL PONDS ❑ y _ <br /> _ i <br /> I hereby certify that(,have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an <br /> rules and regulati6ns'of the San Joaquin Local Health District. work for <br /> Home owner or lines�uch mannergas to b some subject Ito w�orkman'srtify that in the compensation laew`s of California."rformance of Contractor's hiring or sub contrectinglsignlature r <br /> employ any persa <br /> certifies the following:"I certify that in the performance of'the work for which this permit is issued,1 shall employ persons subject to workman's compen <br /> sa <br /> tion laws of California." <br /> The applicant must c l for li required in'�spections. Complete drawing onreverseside. A~ t 4 l� y <br /> ri � Y..o,..Ti �— _: Date: •°C <br /> <�. Title: �-.__-� <br /> Signed . ._ ..� "^ <br /> �y FOR,DEPARTMENT USE ONLY <br /> ' <br /> Area <br /> Application Accepted'by <br /> Date i <br /> Date Final Inspection by f <br /> Pit or Grout Inspection by t _ <br /> } <br /> Additional Comments. ,� " <br /> ' J❑-Manteca 823-7104 ❑ Tracy 835-6385 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 s <br /> Applicant Return aA copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED ` ASH RECEIVED 8y DATE <br /> PERMIT`NO. <br /> INFO <br /> +'EH 1324 lREV.+/a SY <br /> Eli 14-28 '��' <br />