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i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA I <br /> Telephone I2091,46&*W.84 ~ 4&8 3gZo 4 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> or No. 1862 for wetllpump and the Rules an <br /> d Remade in compliance with San Joaquin County Ordinance No.549 for sewage /r�Io ns o!the San Joaquin <br /> Local Health District. A �I <br /> City �Lot Size � PM <br /> Job Address a E� — yy <br /> M wmvAddress �-� J 007 <br /> jC Phone <br /> Owner's Name <br /> Address <br /> Contractor ��7- <br /> �� = ense no. /rhe Phone���r v <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LJ DESTRUCTION LI <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER El ; <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> 11Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> 7� e of CasingSpecifications <br /> ❑ Domestic I Private El Gravel Pack ❑ Tracy yp Type of Grout ? <br /> l"I Public f 1 Other ❑ Delta Depth of Grout.Seal Yp - <br /> I I Irrigation ­Approx. Depth ! I Eastern Surface Seal Installed by <br /> Repair Work Done 1-1 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material (Below 50'I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I 1 ova septic system permitted if public sewer is <br /> available within 200 feet.) V <br /> Installation will serve: Residence-1� Commercial Other <br /> IL <br />` Number of living units: Number of edrao <br />, Water table depth <br /> Character of soil to a depth of 3 feet: ]�) <br /> E SEPTIC TANK ❑ Type/Mfg Capacity_;l No. Compartments 7u„1 <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation t7 Property Line <br /> 1 <br /> LEACHING LINE No. & Length of lines Total length/size - <br /> FILTER;BED ❑ Distance to nearest: Well U Foundation 10.p Property Line <br /> + SEEPAGE PITS QQ Depth /0& _Size <br /> Number <br /> If SUMPS L] Distance-to.nearesi: Well_f..�IIII Foundation ,— Property Line� - f <br /> DISPOSAL PONDS ❑ <br /> E <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, an <br /> rules and regulations of the San Joaquin Local Health Diltrict. <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, ! 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 applicant I call or all r re pections. Complete drawing on reverse side. <br /> OF <br /> Signed X Title: Date: 1 <br /> FOR DEPARTfNENT USE ONLY <br /> i Date <br /> IF Application Accepted by <br /> Pit or Grout Inspection by <br /> Date Final Inspection b <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., GA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY GATE PERMITNO.- <br /> INFO <br /> Y9 <br /> 1 + EH 13-24(REV.I/H 51cam. i 3']� IIIII C, Q <br /> EH 14-2e <br /> i <br />