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I 'I e - x1 <br /> APPLICATION FOR PERMIT v 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 /> quin all the work <br /> .This <br /> cation <br /> made in compliance maith a to the San <br /> County O dinalnce No.District Health 49 for sewage or 1No. 1862 fort to cwell and/or <br /> pump atnd the Rules and heroin <br /> Regulations of heappnl Joaquis <br /> Local Health District. Gam.s—J <br /> �( _ City Lot Size PM— <br /> Job Address ` <br /> Owner's Name <br /> To f1� Address �&_- Phone <br /> p{ (-YJ (Be No. SL[SL S <br /> Contractor's Nam _—�- Phone r <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION Ll <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER 0 <br /> 3 <br /> t1(2DI—PROP. LINE <br /> DISTANCE TO NEAREST- SEPTIC TANK FOUNDATION �� AG ER LINES DISPOSAL D <br /> AGRICULTURE WELL'{1 OTHER WELL P TS//SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation — <br /> Dia. of Well Casing <br /> Type of Casing— � C 4 Specifications <br /> [X_DomesticlPrivate 4.Gravel Pack ❑ Tracy g— O t 0 <br /> / Type of Grout <br /> El Public ❑ Other ❑ Delta Depth of Grout Seal _—s_ <br /> ❑ Irrigation --"Approx. Det�h ❑EaEastern Surface Seal Installed by <br /> Repair Work Done 9 Type of Pump _' H.F. - 2. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material IBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (Noon bptti Nst stem f Qitted if public sewer is <br /> avaig- iin 200installation 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 /> SEPTIC TANK ❑ Type/Mfg Capacity _� No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of Lines <br /> r" Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Y� 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 call for all required inspec ions. Complete drawing on4everse side. 7 <br /> Title: .3 Al Date: ' y <br /> Signed +' <br /> OR DEPARTMENT USE ONLY <br /> 64,3 <br /> Date <br /> Q � <br /> Application Accepted by <br /> Date Area <br /> Date Final Inspection by Date <br /> Pit or Grout Inspection by ` <br /> Additional Comments: �e <br /> ❑ Stk 466-6781 Lodi 369-3621 ❑ Me ca 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 9 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> RECEIVED BY p DATE PERMIT"NO. <br /> ti INFO f�pr1f —'�b xq i <br /> +E14 13.24 IREV.10/831 a 1-3 a <br /> EH W28 <br />