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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) <br /> /or install the work <br /> . This <br /> cation is <br /> made in compliance witade h Sano the Joaqu nn Joaquin Local County Ordinance No.549 for sewage or ealth District-for a permit <br /> No. 1862 for we Ildpump and the Rules and herein <br /> R Regulations of the San Joaquin <br /> Local Health District. <br /> (,� j r �`e City Lot Size i PM <br /> Job Address 1 *� <br /> Owner's Name <br /> y� Address <br /> f3,0ntra�e4er �4.. Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 171 DESTRUCTION ❑ <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 /> ❑ industrial ❑ Open Bottom ❑ Manteca. Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 71 Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I 1=irrigation _.-Approx. Depth I I Eastern Surface Seal Installed by W <br /> Repair Work Done 0 Type of Pump H.P. State Work Done _ CIO <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') �J <br /> Depth Filler Material IBelow 50') — l_ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I 1 DESTRUCTION I I JNo septic <br /> available shitem permitted if public sewer is <br /> Installation will serve: Residence� Commercial— Other��-- <br /> Number of living units: Number of bedrooms ._ <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK X Type/Mfg -t~L_ C r�cr Capacity1000_ !Itvl No. Compartments <br /> PKG. TREATMENT PLT. ❑ I Method of Disposal <br /> s <br /> Distance to nearest: Well 12— Foundation�F�0 Property Line r <br /> r <br /> LEACHING LINE ❑ No. & Length of lines Total length/size da <br /> 7,, [ <br /> FILTER BED ❑ Distance to nearest: Well��� Foundation C[l� Property Line ON <br /> V <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 Di3trict. <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 ust call for all re uirad inspections. Complete drawing on reverse side. <br /> r� <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by ` Date 'Q Area <br /> Pit or Grout Inspection by Date Final Inspection by Date �� <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 523-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201r <br /> C.'ta .K_ 5�,�,� ,�dCS if'Ir p's . Milli* <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> +.EH 13.241REV.1/351 . 7 p <br /> EH 14-2a <br />