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y APPLICATION FOR PERMIT <br /> �yca s <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 /> rk <br /> cation is <br /> madecnticompliance witrhdSanoJoaqu n Coungty Ordinance Nto. 549 for sewage permit <br /> 1862 for wel/dpuomp install <br /> nd the Rues and hereinR gulations of the San f Joaquin <br /> Local health District. <br /> City— Lot Size PM <br /> Job Address <br /> c ^ �„ ( .e..t.� Phone <br /> Owner's Name Address <br /> Contractor Address <br /> License No/ X973 Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL. REPLACEMENT © DESTRUCTION El <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> It <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPbSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PkTS/SUMP <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Diad of Well Excavation <br /> f Dia. of Well Casing <br /> 171 Domestic/ ❑ Type of Casin Specifications DomesticlPrivate A Gravel Pack <br /> Tracy r 9 <br /> F'1 Public Cl Other F1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth i I Eastern Surface Seal Installed by - <br /> Repair Work Done E� Type of Pump ���' H.P. State Work Dane_ <br /> I 1 <br /> Wel.Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth+ .i. Filler MateridIBelow 501 - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I') REPAIR/ADDITION I I DESTRUCTION I I (No'sepiic system permitted if public sewer is <br /> available within 200 feet) <br /> Installation will serve: Residence t _,.Commercial�NOtheri <br /> Number of living units: Number of bedrooms <br /> I" . - Water-table depth <br /> —Character of sod to a depth 3 feet: <br /> SEPTIC TANK ❑ ,;Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ 1 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> y Total length)size <br /> FILTER BED "❑ Distance to nearest: Well (Foundation Pro perty <br /> _ SEEPAGE PITS { I Depth Size la Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Li9VVP0NVTNTAL HEALTH <br /> DISPOSAL PONDS ❑ �- :b s.. -'> - =_ J-- <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 /> l rules and regulations of the San Joaquin Local Health District. , <br /> Home owner or licensed agent's signature certifies the following: "I certify'th'at 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.'iContractor's hiring or sub-contracting signature <br /> certifies the fallowing: "I certify that in the performance of the work for wtlich this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> r ! <br /> The applicant m all r all re iced " spections. Complete drawing 41r1everse side. r r, <br /> } -- <br /> I Signed X Date: <br /> �FOREPTMENT USE ONLY �/ AreaApplication Accepted by Date „ <br /> ' f �m <br /> Pit or Grout Inspection by Date Final Inspection by�— <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 C1 Manteca 823-7,104 ❑ Tracy 635 6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, 51k., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. <br /> INFO <br /> +.EH 13-24(REV. /rs sl <br /> EH 14-2a <br />