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APPLICATION FOR-PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> !PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) ` <br /> ribe <br /> ,This <br /> cation is <br /> t an /or install the work heren desc <br /> Application is heieby <br /> with SanpJthe San Joaquin Local Healh District for a permt to oaquin County O d nance Nto.549 for sewage or INo. 1862 for well/dpump and the R les and'R gulations of the San l Joaquin <br /> made in compliait <br /> Local Health District. <br /> Ire _ City C_ r of Size PM <br /> Job Address - <br /> G - <br /> Address Phone <br /> Owner's Name <br /> _ 3 <br /> Contractor Address ' <br /> L DkiLicense No. Phone 0 <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> ` DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> 9 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ClManteca - Dia.-of,WeB..Excavation—- Specifications <br /> ck <br /> ❑ Domestic/Private ❑ Gravel Pa ❑ Tracy Type of Casing <br /> _; i Type of Grout <br /> r ❑ Other Cl Delta Depth of Grout Sea!" <br /> ❑ Public . _ - <br /> --. -Approx. Depth I l Eastern Surface Seal Installed by— <br /> ( Irrigation• State Work Done— <br /> Repair Work Done` CKI <br /> ❑ Type of Pump H.P. �( <br /> Well Destruction ❑ Well Diameter Sealing Material Stop 501 �- <br /> Depth Filler Material lBelow 50`1 <br /> NEW INSTALLATION I PAIRIADDITION l I DESTRUCTION l I (No septic Yst 200 feet.) if public sewer is �J�l <br /> PTIC WORK: <br /> available TYPE QF 11 SE <br /> Installation will serve: Residence_L_--,Commercial Other <br /> Number of living units: __L_ number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> ❑ Type/Mfg Capacity'/ — <br /> SEPTIC TANK " Method of Disposal <br /> s PKG. TREATMENT PLT. 11 �� '� Property line-._ZboZ <br /> Distance to nearest: Well J695 - Foundation <br /> LEACHING LINE 10- & Length of lines Total length/size <br /> We <br /> FILTER BED ❑ Distance to nearest: N _ — Foundation_?)5 Property Line <br /> r . <br /> Size r Number <br /> SEEPAGE PITS t.}�opth Property Line <br /> SUMPS Ll Distance to nearest: Well Foundation p rtY <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordarice with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health Di§trict. <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 /> 1 employ any person in such manner as to become subject to workman's compensation laws of California." Contra�OSOnhisubject ru warkmantlsgompensa- <br /> 1 cart signature <br /> ifi a following: "I certify that in the performance of the work for which this permit is issued,I shall employ p <br /> # tion laws o `e"forni +" <br /> The applicant all for ll r vire i s. omplete drawing on reverse ide. J - <br /> � Date: <br /> Title: <br /> Signe _ - <br /> FOR DEPARTMENT USE ONLY s <br /> Date `� Area = <br /> Application Accepted by -- -P <br /> Date Final Inspection by Date <br /> Pit or Grout inspection by <br /> Additional Comments:. <br /> ❑ Stk 466-6781 ❑ Lodi 369 3621 ❑ Manteca 823-7104 ❑ Tracy 835- <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P_O. Box 2009, Stk., GA 95201 <br /> FEE CK RECEIVED BY DATE PERMIT'NO. <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> t,EH 13-24 1REV.It k 51 `� �A <br /> EH 14-26 <br />