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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �} <br /> 1601 E. HAZELTON AVE., STOCKTON, CA /\ <br /> Telephone (209) 466.6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) I✓V/, <br /> Application is hereby made to the San Joaquin Local Health District fora I <br /> made H compliance with San Joaquin County Ordinance No.599 for sewage No. 1862 forcwell/pu and/or nstall the work heroin and the Rules and Regulations. This of he San Joaquin <br /> is <br /> is <br /> Local Health District.) /h! Joaquin <br /> �9 <br /> Job Address <br /> L City of SI PM <br /> Owner's Name ) / <br /> Address <br /> Phone <br /> Contractor's Name <br /> ' License No. ,_ ? rfy <br /> TYPE OF yyELL/p�p: NEW WEL ❑ Phone <br /> WELL REPLACEMENT ❑ DESTRUCTION7!INE <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER <br /> SEWER LINES - DISPOSAL FLD. <br /> FOUNDATION AGRICULTURE WELL <br /> OTHER WELL _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom <br /> El Manteca <br /> Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private El Gravel pack ❑ Trac <br /> ❑ Public y Type of Casing Specifications J <br /> ❑ Other El Delta Depth of Grout Seal <br /> 13 Irrigation --Approx. Depth ❑ Eastern AType of Grout �– <br /> Sur/ace Seal Installed by <br /> Repair Work Done ❑ Type of Pump H p <br /> Well Destruction ❑ State Work Done <br /> Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 501 �---+ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/�gDDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> Installation will serve: Residence— Commercial/p//Other available within 200 feet.) <br /> Number of livingunits: <br /> Number of bedrooms � <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK Water table depth <br /> ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well A"rication Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well —� ,Foundation <br /> Property Line ---- --, <br /> S PAGE PITS ❑ Depte (J � �� Number <br /> SUMPS ❑ Distance to nearest: Well�.Q-(,.l. oundation , <br /> TITSMSAL PONDS ❑ Property Line <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: "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 California." <br /> The applicant must call <br /> --for <br /> ��all r". d 'inspections. Complete drawing on reverse side. <br /> Signed X—_ �' j� Title: - Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by �C� ( Date Arm <br /> Pit or Grout Inspection by Date - Final Inspection by1.`1 - ' <br /> Date <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 AMOUNT REMITTED CK <br /> INFO —? <br /> CASH RECEIVED BY DATE PERMIT NO. <br /> s EH 1}24(REV.ICIINFO <br /> / <br />