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APPLICATION FOR PERMIT �L 6 <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 /> ation is <br /> Appication is /or install the work <br /> madle in compliance with Sano)aqu nthe SanCou JoaQty Ordinance Nto.549 for sewage or permit <br /> 1862 for cwell/dpump and the Rules and herein <br /> gulations of tthe San is l Joaquin <br /> Local Health District. <br /> fp <br /> City Lot SizePM <br /> Job Address �-7 <br /> r r Phone <br /> Owner's Name ! idress <br /> # r <br /> Contractor <br /> ddress License Not Phone <br /> TYPE OF WELL/PUMP: NEW ELL ❑ WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> Type of Casing Specifications <br /> El Domestic/Private ❑ Gravel Pack ❑ Tracy Yp g Type of Grout <br /> __­ <br /> F Public ❑ Other 17 Del <br /> Depth of Grout Seal YP <br /> I I irrigation _Approx. Depth I 1 Eastern Surface Seal installed by 1, <br /> Repair Work Done [_� Type of Pump <br /> H P State Work Done <br /> Scaling Material (top 50'1 4 �' <br /> I Wel! Destruction ❑ Well Diameter _ g <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION i I DESTRUCTION i I (No sepavarrlable w thin 2'ern00 feetc sy tem .) if public sewer is <br /> Installation will serve: Residence Commercial— Other ((� <br />! Number of living units: _.— Number of bedrooms_ —� ' <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg ` Gapacity No. Compartments <br /> Method of Dis sal <br /> PKG. TREATMENT PLT. ❑ r ^� <br /> Distance to.nearest:., Well Foundation. Property Line .— <br /> F r <br /> LEACHING LINE'S Cl No. & Length of lines Total Iengthlsize <br /> FILTER BED ❑ Distance to nearest: Wel! "�FoGndatiiiPfoperty Line <br /> SEEPAGE PITS I I Depth Size Nf mber <br /> SUMPS Ll Distance to nearest: Well __. Foundation _— Property Line .— <br /> DISPOSAL PONDSEI <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 perfofmance 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 us It fa all req re inspection Co _ lete drawing on reverse side. <br /> Signed X <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date Araa <br /> Pit or Grout Irispection by <br /> —Date a� Final Inspection by Date <br /> 1 <br /> Additional Comments: <br /> I ❑ 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 /> ffFF CK RECEIVED BY DATE PERMIT NO. <br /> l EZZ±AMOUNT REMITTED CASH♦ I=H 13-241REV.5/K 51 <br /> I EH 14-29 <br /> I -- <br />