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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA ' <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> /or install the work <br /> n described. <br /> is <br /> Application <br /> with Sanade othe San Joaquin Joaquin Comy Ordinalnce No.549 for sewage ealth District for a or 1t to No 1862 for construct <br /> Ypump and the Rules and'Regulations of tthe Sanapplication <br /> Joaquin <br /> Local Health District. <br /> •� 1� —� . l� ) 1�(d. `�r Cit Lot Siz PM <br /> Job Address <br /> OAddress <br /> Owner's Name <br /> Phone fJ d <br /> t' JL PrTTf Wf CA ovq�a <br /> "' License No. Phone <br /> Contractor Address y <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 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 /> ❑ Industrial LJOpen Bottom ElManteca Dia. of Well Excavation <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r <br /> M Public n Other 17.1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation "Approx. Depth ( I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump N.P. State Work Done_ Q <br /> Well Destruction Ij Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material IBalow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIWADDITION 1.1 DESTRUCTIOPKV iNo septic system <br /> m permitted if public sewer is <br /> feetA <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> G. TREATMENT PLT. ❑ Method of Disposal <br /> PK , <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i I Depth Size Number <br /> f SUMPS L1 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: "t 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 /> I The applicant mut call for It required ' Spec ion Complete drawing on reverse side. <br /> k Signed X t 4 Title: ��c '— =-� Date: <br /> f 01 FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> j Additional Comments. <br /> ❑ Stk 466-6781 Lodi 369-3621 Cl 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., CA 95201 FEE AMOUNT DUE AM;UNT REMITTED CASHRECEIVED BY DATE PERMITNO. y4f <br /> )NFO _ (,jTr t/ GN+ EH 13-241REV.i/95) f "V VJ (� �� <br /> EH 14-2e <br />