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APPLICATION FOR PERMIT <br /> IM SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE1,TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> �l <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 /> welllpump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for <br /> Local Health District. <br /> Q I� <br /> Job Address <br /> 13© City Lot Size PM <br /> Owner's Nam <br /> Address ° Phone <br /> k :! <br /> Contractor r Address .�. {� License No. i?, Z(p Phone R <br /> TYPE OF WELL/PUMP. _. NEW WELL EIWELL REPLACEMENT ❑ DESTRUCTION 11 {� <br /> I r <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ <br /> DISTANCE.TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wel! Casing <br /> LJ Industrial <br /> Domestic/Private 1711 Gravel Pack EI Tracy Type of Casing Specifications t <br /> {'l•Public [-IOther17 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation . _'� .Approx. Depth l I Eastern Surface Seal Installed by - r, <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction C7 Well Diameter Sealing Material (top 501 <br /> t pepth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION, l I DESTRUCTION l I INo septic system permitted if public sewer is <br /> .. ,„. -- .-. available within 200 feet.)-- <br /> Installation will serve:a"'ResidenceCommercial= Other <br />( Number of living units: !' Number of dooms O <br /> Character of soil to a deptfioof 3 feet: Water table depth <br /> "SEPTIC TANK Type/Mfg I Capacity L(Or_() No. Compartments <br /> PKG. TREATMENT PLT. 1-1 ' f � r Method of Dis�osai <br /> `+x 'Distance to nearest: Well _loo Foundation__ls�— Property Line <br /> LEACHING LINE L�No. 8 Length of lines Total length/size a x <br /> FILTER BED El ii Distance to nearest: Well 66 Foundation�._-..— Property Line -4; "F F <br /> rt <br /> SEEPAGE PITSl Depth -a5 Size Number <br /> f <br /> f SUMPS L'rl�Disiance-to-nearest: Well --Foundation_ 1 O� Property Line__7,Tx_ <br /> pISPOSAI�PONDS ID s ~ <br /> ( hereby certify that I have`piepared`this 80plication: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. 1 k <br /> Home owner or licensed agent's signature-certifies the following: '9 certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such irianner as to'liecome subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: Icertify that in the performance of the work for which this permit is issued,t shall employ persons subject to workman's compensa <br /> tion laws of California." <br /> The applicant t call for a Ired inspections. Complete drawing on reverse side. <br /> r <br /> Date: l <br /> Signed Title: r <br /> 'i Nr <br /> FOR DEPARTMENT USE ONLY f <br /> Date Area / <br /> r Application Accepted by <br /> Pit r Grout Inspection by <br /> ' Date Final Inspection t <br /> Additional Comments: I' <br /> F ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Mante6a,1823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all capiasto: Environmental Health Permit 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> Il �+ <br /> FEE AMOUNT DUE AMOA7 REMITTED CASH RECEIVED BY DATE PERMIT N0. <br /> INFO <br /> + EH 1324 1REV.�i H 5Y "� �s <br /> EH 14-2a <br /> I r <br /> , F' <br />