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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) <br /> Appliaon is <br /> cation is <br /> madeontkcompliance wetebytith SanoJoaqu nthe SanCounty Ordinance NJoaquin Local to. 549 for sewage or h District for a permit <br /> 1862 for well//pump and the Rules and Regulations of he Sank Joaquin <br /> Local Health District. <br /> Joh Address v' I ! <br /> �]9 } . City Lot Size PM <br /> // <br /> Address �`' Phone <br /> Owner's Nam /j / <_ <br /> ContractoG C <br /> + ( Address 76_ZX y License No Y Z Z( Phor <br /> -14U: 'a <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Ll <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> E7 Industrial ❑ Open Bottom C3 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [I Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications <br /> F] Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> 1"1 Irrigation _.-Approx. Depth l I Eastern Suriace Seal Installed by - <br /> Repair Work Done ElType of Pump H.P. State Work Done <br /> Well Destruction C. Well Diameter Sealing Material (top 50;) <br /> Depth iter Material (Below 50 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ] REPAI ADDITION DESTRUCTION I 1 iNo septic system permitted if public sewer is <br /> available within 200 feet.I <br /> Installation will serve: Re idenceCommercial ther <br /> Number of living units: Number edroo <br /> Character of soil to a deptff of 3 feet: Water table depth- <br /> `' "— Capacity=— No- Compartments <br /> SEPTIC TANK LJType/Mfg Y _ - <br /> PKG. TREATMENT PLT. ❑ - - Method of Disposal <br /> Distance to nearest: Well ry Foundation-_J Property Line <br /> LEACHING LINE ttf' No. & Length of lines Total length/size X <br /> FILTER BED ❑ Distance to nearest: Well �`�Q Foundation h Property Line_�. — <br /> SEEPAGE PITS INT Depth Size (Number - <br /> I,�,�r <br /> SUMPS 0 Distance to nearest: Well ADD "Foundation A0 Property Line <br /> DISPOSAL PONDS ❑ /q+ <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, andl� <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 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 m all for a1 u' d inspections. Complete drawing on reversedo. <br /> ned X <br /> Title: r Date 44 <br /> Sig <br /> FOR DEPARTMENT USE ONLY e <br /> Application Accepted by Date Area l <br /> Pi ar Grout Inspection by d ate Final Inspection by Data`�I <br /> Additional Comments: <br /> ❑ 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 /> FEE AMOUNT DUE AMOUNT REMITTED CA$H RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> ♦ EH 13-241REV.7/H51 <br /> EH 14.26 c:, <br /> f� <br />