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a APPLICATION.FOR PERMIT <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)ealth ' <br /> /or install the work <br /> .This <br /> cation is <br /> Application is;ancg made <br /> h Sanothe San Joaquin Local HJoaqu n County Ordinance No.D549 for for <br /> or No. 1862 forcwell/dpump and the Rules and herein <br /> Reguicatio�of the Sanr Joaquin <br /> made in.comp „.. , <br /> Local Health District. Y v3, X.l`Q <br /> .�:�• : 2 r. rJ City u Lot Size PM <br /> Job Address <br /> r: S s 2- <br /> )no <br /> 2 5 <br /> Owner's Name W 6 Address 1 O7 CC <br /> License No. Phone <br /> Contractor Address <br /> PE OF WELLlPUMP: � ', Ni�-WELL ❑ "" "'' WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> I SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ <br /> DISTANCE TO N <br /> SEPTIC TANK SEWER L1NES DISPOSAL FLO. PROP. LINE <br /> FO N AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL LFM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Open Bottom Ll Manteca _ Dia. of WeII Excavation <br /> Industrial Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type o Type of Grout <br /> I <br /> ❑ Public <br /> C,Other - ❑"Delta ;Depth of°Grout Sea , <br /> ❑ Irrigation _�pprox..Depth 11 Eastern Surface Seal Installed by <br /> i <br /> State Work Done <br /> Repair Work Done Ll Type of Pump <br /> H P <br /> Well Destruction ❑ Well Diameterr i Sealing Material {top 50'} <br /> -`Depth + �-. Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: ;--NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No <br /> septilablewith tem peflee tted if public sewer is <br /> Installation will serve: Residence, Commercial_ Other <br /> Number of living units: Number of'bedroomsV Water table depth <br /> Character of soil to a depth of 3 feet: <br /> ' Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: : Well Foundation Property Line <br /> LEACHING LINE ElNo. & Length of lines + <br /> Total-length/size <br /> FILTER BED El Distance to nearest: Well Foundationr ;` l�Property Line f <br /> w 5 S <br /> SEEPAGE PITS ❑ Depth Size '° Number <br /> SUMPS ❑ Distance to nearest: Well 'Fouridation'� Property Line <br /> DISPOSAL PONDS ❑ + <br /> 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 /> empioy any person in such manner as io-become subject to workman's•compensation-flaws 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 for all required inspe ions. Complete drawing on reverse side. , <br /> Signed ti Title: <br /> Date: ! <br /> FO EPA T USE ONLY <br /> yDate <br /> Are---a <br /> . <br /> . _ <br /> Application Accepted by <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date y`Z�' 9 <br /> Additional Common Y _26 <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 63546385 <br /> Applicant- Return all copies to: Environmental Health Permit/Servioes 1601 E. Hazelton Ave,., P.O. Box 2009, Stk., CA 95201 <br /> -mom —FEE. AMOUNT-DUE`- —AMOUNT REMITTED` �' RECEIVED'BY'` DATE " '"'PERMIT''NO.-� <br /> INFO 3 <br /> em <br /> + EH 13.24ME:V.1ie5) <br /> 'EH 14.26 <br />