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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. NAZ-L T ON ,AVE,, STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> is <br /> Application is hereby mhdSanothe Joaquin County Ordinance Local <br /> lNto.549 for sewage orpermit <br /> No. 1862 forconstruct <br /> well/pump and the Rules and herein <br /> Regulations of tlhe Sanapplication <br /> Joaquin <br /> made in compliance w <br /> Local Health District.' l9`]p 1674, <br /> .. l' City Lot Size PM <br /> Job Address <br /> ,�� Phone <br /> Owner's Name Address + <br /> Contractor <br /> Address 7 License No. Phone <br /> TYPE OF WELUPUMP: NEW WELL ❑ WELL REPLACEMENT ElDESTRUCTION;❑ <br /> PUMP INSTA TION El- SYSTEM REPAIR­ <br /> DISTANCE <br /> Q. <br /> DISTANCE TO NEAREST:.SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP.,LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL- <br /> INTENDED <br /> ELL 1 PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM A CONST CTiON SPECIFICATIONS i , <br /> ❑ Open Bottom ❑ Manteca f Well Excavation Dia. of Well Casing <br /> ❑ Industrial f <br /> 'Specifications <br /> ❑ Domestic/Private Cl Grave! Pack 11 Tracy pe o sing , Type of Grout - <br /> fl Public f i Other FI Delta Depth of Grou al <br /> I i Irrigation _-Approx. Depth I 1 Eastern h. Surface Seal Installs -' - <br /> Repair Work Done L] Type of Pump P• state rk Done _ <br /> " <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 (� <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION K REPAIR/ADDITION i I DESTRUCTION I I (No sepsy <br /> avail abetiwithine200 feetFtyed if public sewer is <br /> 1 <br /> Installation will serve: Residence j;ommercial_ Other 7— <br /> !. . r" <br /> Number of living units: / Number of bedrooms ,r " <br /> !l Water table depth <br /> f Character of soil to a depth of 3 feet: v ONO <br /> i Capacity 4?� No. Compartments <br /> SEPTIC TANK 11'Type/Mfg <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well ASP4 Foundation +30 Property.Line 7 — <br /> LEACHING LINE L- No. & Length of lines Ta�I length/size <br /> "FILTER HED ❑ Distance to nearest: Well 5� Foundation � Property Line <br /> SEEPAGE PITS ll�e Depth �S Site, N�mber <br /> SUMPS Cl Distance to nearest: Well ..._-.- Foundation <br /> /75 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." Contractors 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 applicant must call for I required inspections. Complete drawing on reverse side. <br /> X <br /> Title: �> Date: <br /> ). <br /> FOR r EPARTMENT USE ONLY ! / <br /> Area <br /> Date <br /> l <br /> Application Accepted by a f f ! <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments:Z2 Z-J' n �, ft✓ _e <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ M teca 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 55201 <br /> FEE CK RECEIVED BY DATE PERMIT"NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH', <br /> +,EH13-244REV.��H51 �D.a� U t <br /> EH 14-20 <br />