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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 describe . This <br /> cation is <br /> madeCntcompliance with Sano <br /> 9Joaquin Coungty ordinathe San Joauin nce No.549 for sewage o ealth District for a permit <br /> 1862 for well/dpump and the Runes and IR gulations of the San l Joaquin <br /> Local Health District. <br /> Job Address <br /> (� t Q (� City Lot Size_.]�'L�. PM <br /> +. Phone <br /> Owner's'Name Address <br /> ss. 36 TJ <br /> Address - License No. SO c5� __Phone <br /> Contractor �� T .� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> E] Domestic/Private 1-1Gravel Pack % F1Tracy Type of Casing Specifications I <br /> Type of Grout <br /> ('l Public. 17 Other ❑ Delta Depth of Grout Seal <br /> + F <br /> I Irrigation ' —__Approx. Depth 14TEastern Surface Seal Installed by <br /> rH H.P. <br /> State Work Done <br /> Repair Work-Dane 0 Type of Pump <br /> Well Destruction r' ❑ Well Diameters _ »� Sealing Material (top 50'1 <br /> t Depth Filler Material (Below 50'I — <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION DESTRUCTION l I (No septic system permitted if public sewer is 1 <br /> available within 200 feet.l <br /> Installation will serve: Residence Commercial Other i <br /> Number of living units: � INumber of b'd ooms-' % I a <br /> + — Water table depth 1 <br /> Character of soil to a depth of 3 feet:.. , <br /> SEPTIC TANK f3.- Type/Mfg Capacity No. Compartments J <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ r <br /> Distance to nearest WeII `/® r Foundation Property Line <br /> s( '• A <br /> LEACHING LINE C�YNo. & Length of lines O Total length/size <br /> FILTER BED <br /> ❑ Distance to nearest: Weill I Foundation _O 1 Property Line V <br /> :F a <br /> SEEPAGE PITS 14/Depth r Siie Number <br /> SUMPS i �-- ❑--Distance to nearest: �- Well �+"Foundation L. -Property Line -- <br /> DISPOSAL PONDS ❑ <br /> 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 /> rule's 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 Ca lifornia." <br /> The applint•m st call for ail re trod nspemions. Complete drawing on reverse side. <br /> Signed X <br /> Title: �t9tif Date: <br /> i t FOR DEPARTMENT USE ONLY <br /> ` s <br /> Application Accepted by1 17 <br /> Date <br /> or Grout inspection by Date r al Inspection by - <br /> 1 <br /> i 111 ' <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., CA 95201 <br /> FEE• - AMOUNT DUE---'""'AMOONT REMITTED+' CASH RECEIVED BY' DATE PERMIT NO. <br /> /�1 ``4 <br /> + EH 13-24(REV.t/n51INFO S�q VT � '0!� S-9__w <br /> EH 54-28 <br />