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r 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 /> k <br /> (Complete in Triplicate) <br /> all the work <br /> n described. <br /> cation is <br /> Application is hereby made to the San County OLdinalnee No.549 for sewage or ealth District for a permit <br /> No 1862 forcwellap�mp and the Rules and IR gulations of tthe Sanis d Joaquin <br /> made in compliance with San Joaquin ' <br /> Local Health District. <br /> ~7/1 7 Lot Size PM <br /> City ' <br /> cam / <br /> Job Address <br /> SV3 <br /> Address r / <br /> q M- Phone <br /> ; <br /> Owner's Name i <br /> License No. Phone <br /> Contractor_ __ Address _ L WEM - - <br /> NEW WELL ❑ WE REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: ' . STEM REPAIR ❑ �-OTHER ❑ <br /> PUMP INSTALLATION ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINEDISTANCE TO NEAREST: SEPTIC TANK �� - <br /> FOUNDATION AGRICULTUOTHERWELL PITS/SUMPS <br /> RE WEL <br /> INTENDED USE TYPE OF WELL PROBL.EIV!/�REAa CONSTRUCTI PECIFICATIONS Dia. of Well Casing �\ <br /> Open Bottom ❑ Manteca Dia:;of Well Exc t' n <br /> Industrial ❑ Op S ecifications <br /> ❑ Indus of Casin P ' <br /> T e 9 � <br /> Pack ❑ Tracy yP <br /> {7 Gravel Pac f Grout _. <br /> ❑ Domestic/Private Type o <br /> ❑ Other Ll Delta Depth of Grout Seal <br /> I I Public Surface Seal Installed by <br /> I I Irrigation ,.Approx. Depth 11 Eastern <br /> ,H P State Wor one <br /> Repair Work Done ❑ Type of Pump Sealing Material Stop 501 <br /> Well Destruction ❑ Well Diameter Filler Material if3elnw 50') <br /> Depth �... <br /> s <br /> TYPE OF,SEPTIC WORK: NEW INSTALLATION l 1 REPAIRlADD!TION DESTRUCTION l I available'wi-within 200 feet.)septc system if public sewer is ` <br /> ! <br /> installation will serve: Residence_X Commercial. . Other <br /> +� Number of bedrooms , <br /> l .Number of living units: ,� ' ' Water table depth <br /> Character of sail to a depth of 3 feet: o, Compartments <br /> Capacity <br /> SEPTIC TANK ❑ Type/Mfg Method of_•,Disposal t <br /> PKG. TREATMENT PLT. 0 v <br /> Distance to nearest: Wel! ,_Fouhdation Property.Line <br /> r _ <br /> No. & Length of lines <br /> LEACHING LINE Total Iengthlsize g I Pro Line <br /> ❑ Distance to nearest: Well GTS Foundation_ — Property — �- <br /> FILTER BED , <br /> / Size C/ Number <br /> SEEPAGE PITS I I Depth _ '�j / property Line <br /> t SUMPS Ll Distance to nearest Well Foundation <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that l have prepared this application and the the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> l rules and regulations of the San Joaquin Local Health Dltrict. work for <br /> l not <br /> Home owner or licensed agent's signature certifies subject lfo wlogk.- ; compensation I: "I certify that in the performance <br /> California."Contractor's which <br /> thvi gr or sub-contracting lsignlaturre <br /> employ any person in such manner as to be _ <br /> of the work far which this permit is issued, I shall employ persons subject to workman's compensa <br /> certifies the following: "I certify that in the performance <br /> tion laws of California." <br /> The applicante.., hf etl req din cfl�ans. Complete.drawing on;averse side. <br /> +) , Title: Date: <br /> Signed X <br /> DEPARTMENT USE ONLY <br /> Date r / Area <br /> Application Accepted by <br /> ' final Inspection by Date <br /> f <br /> Pit r Grout Inspection by "tom ,, <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621-•�"`❑-Mshteca 823:71D4 ❑ Tracy-635-6385 <br /> r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk:, CA 96201 <br /> CX RECEIVED By DATE PERMIT'NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> •-EH 13-241REV.I K5) <br /> EH 14-26 <br />