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OR PERMIT <br /> APPLICATION F <br /> r ` HEALTH DISTRICT <br /> P1 <br /> ]� SAN JOAQUIN LOCA` <br /> ,VE., STOCKTON, CA <br /> 1601 E. HAZE T ON 209) 466-6781 <br /> Telephone = <br /> EAR FROM DATE ISSUED <br /> PERMIT EXPIRES 1' <br /> .plete in Triplicate) <br /> (Corr <br /> *- ct andlor install the work herein described. This application is <br /> Lrict for a permit to constru <br /> Application is hereby made to the San Joaquin Local Health Did9 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.5 <br /> Local Health District. <br /> City &rte l Lot Size © r PM <br /> Job Address <br /> 7 Phone : <br /> x Address <br /> Owner's Name. �r <br /> License No._Vre �_a Phone <br /> Contractor - WELL REPLACEMENT ❑ DESTRUCTION [� <br /> NEW WELL� � OTHER i] <br /> TYPE OF WELLIPUMP: P SYSTEM REPAIR ❑ <br /> PUM^ INSTALLATION), _ - _ . . <br /> r <br /> PTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTAN�E TO NEAREST: Sr`- AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> FOUNDATION <br /> �`. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> EJ❑ Open Bottom ❑ Manteca .,Di,, of Well Excavation <br /> ❑ Industrial Type of Casing Specifications <br /> lKDomestic/Privzote Gravel Pack ❑ Tracy Yp Type of Grout_1.� <br /> C} Other ❑ Delta Depth of Grout Seal _�—, - <br /> FI Public �� _ <br /> I I Irrigation ')"Approx. Depth I I Eastern Surface Seal Installed by <br /> �_ H P State Work Done <br /> Repair WOW( Done L3 Type of Pump (J <br /> (ruction ❑ Well Diameter _, - jW Sealing Material Itop 50'1 <br /> Well Des( <br /> Depth__—?�/� Filler-Material (Below 50'1 <br /> ' ;TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIRIADDITION 1.I�,DESTRUCTION t 1 availabeseptic <br /> within 200 feet.)ied ipublic sewer is <br /> GN <br /> Installation 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: No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well Foundation <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines <br /> t <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> f Number <br /> { SEEPAGE PITS l I Depth Size Property Line <br /> SUMPS Ll Distance to nearest: Well Foundation P Y <br /> DISPOSAL PONDS ❑ <br /> I 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 /> "1 certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: <br /> compensation_laws of Galifornia.'�Contractors hiring c sub,contracting signature <br /> employ any person in such manner as to become subject to workman'.s <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa <br /> t tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Title: 4(f Date: <br /> Signed X �� , <br /> FOR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by 2tM <br /> t Pit or Grout Inspection by <br /> Date Final inspection by Date <br /> m <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Me eca 823-71& ❑ Tracy 835-M85 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEERECEIVED BY DATE PERMIT NO. <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO S <br /> +.EH 13-21(REV.1/9 5) <br /> EH 14-26 <br />