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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) application is <br /> stall <br /> or No. 1862 for <br /> Application is heteby made to the San Joaquin Local Health District for a permit to construct and/or and the Rules and Regulations of the San Joaquin <br /> the work herein described. This app <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage well!pump and <br /> Local Health District. <br /> iCity Lot Size � M <br /> Job Address ST/<T <br /> - Phone <br /> I� Owner's Name �r !� <br /> µ icensePhon� <br /> //.,/ e4oddress milip <br /> Contractor WELL ill''",',,'''', DESTRUCTION❑ DESTRUCTION ❑ <br /> TYPE OF WELLIPUMP: NEW WELL OTHER ❑ <br /> PUMP INSTALLATION Lam^ SYSTEM REPAIR ❑ <br /> �� EWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK8��,-AGRICULTURE WELL OTHER WELL PITS/SUMPS �J�J <br /> FOUNDATION <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> ravel Pack ❑ Tracy Type of Casing„ <br /> 91. omestic!Private Type of ou <br /> 11 Other Ci Delta Depth of Grout Seal <br /> 1=1 Public Surface Seal Installed by <br /> I I Irrigation a�pprox. Depth I 1 astern State Work Done <br /> Type of Pum c H.P- <br /> Repair Work Done ❑ e p Sealing Material (top 50'1 <br /> Well Destruction ❑ Well Diameter <br /> 501Depth Fitter Material (Below 5D <br /> available within 200 feet.] ! <br /> TYPE OF PTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION I 1 DESTRUCTION i I (No septic system permitted if public sewer is <br /> SE <br /> - Hattan vill`seive: 'Resid`enci3" ";C6mm6rcial- Other <br /> x Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: Capacity__--_--- No, Compartments <br /> SEPTIC TANK ElType/Mfg Method of Disposal <br /> a PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well <br /> Foundation Property Line <br /> Total length/size � <br /> LEACHING LINE ❑ No. & Length of lines property Line <br /> FILTER SED <br /> ❑ Distance to nearest: Well Foundation <br /> Size Number <br /> SEEPAGE PITS i 1 Depth property Line e <br /> SUMPS ❑ Distance to nearest: Well Foundation P rty <br /> DISPOSAL PONDS ❑ <br /> l will be done in accordance with San Joaquin county ordinances, state laws, and <br /> 1 hereby certify that I have prepared this application and that the work <br /> rules and regulations of the San Joaquin Local Health District. <br /> l not <br /> Home owner or linenssuch manner as to become subiectt to workman's atufe certifies the following: "I lompensat on lthat in the awsoof California." Contract r'whrmance of the work for ir ngl or sub-contracting lsignlaturre <br /> l employ any p persons subject to workman's compensa- <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ p { <br /> tion laws of California." <br /> The applicant must call for all required inspect�J­�p late drawing on reverse side. <br /> Title: Date: T �{ <br /> Signed X �F <br /> FO EPARTMENT USE ONLY <br /> �. Date I <br /> Application Accepted by t ` ! f �- <br /> ��"� Final Inspection by Date <br /> Pit or Grout Inspection by Date <br /> r' <br /> Additional Comments: ! <br /> ❑ 5tk 466-6781 D Lodi 369-3621 0-Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services. 601 E. Hazelton Ave., P.O,/,Box 2009, Stk., CA 95201 <br /> DATE PERMIT�NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH- <br /> RECEIVEDfBY <br /> INFO <br /> + EH 13-24(REV.y/n 5) ! <br /> EH 14-26 <br />