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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 /> ,Y (Complete in Triplicate) <br /> n describedThis <br /> cation is <br /> Application is hereby made o the <br /> SanJoa County Ordinalncte No.549 for sewage or ealth District for a permit <br /> 1862 for cwell pump and the Rules and t and/or install the work IR Regulations of the San Joaquin <br /> made in compliance with Sanq + <br /> Local Health District.1—"l f �r��� <br /> PM36CityLot 5iza <br /> Job Address <br /> r <br /> l G <br /> �.0 � i L Phone �6 j <br /> Owner's Name - Address <br /> — � 1 <br /> Address License No. Phone <br /> Contractor <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 <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—PITS/SUMPS s' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing. <br /> Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack C73 Tracy Type of Grout <br /> M Public <br /> I:} Other C1 Delta If Depth of Grout Seal <br /> + " <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by <br /> H P _State Work.Done — <br /> Repair Work Done ❑ Type of Pump -- <br /> Well Destructionf ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material Melo 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/,ADDITION DESTRUCTION I I INo septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residenceff Commercial— Other <br /> Number of living units: _--/-- Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet:l <br /> SEPTIC TANK E] Type/Mfg <br /> Capacity No, Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ t t <br /> Distance to nearest: Well Foundation Property Line <br /> 4 <br /> I LEACHING LINE No. & Length of lines <br /> Total length/size <br /> FILTER BED Distance to nearest: � Well FouatiQ_n Property Line" <br /> SEEPAGE PITS C 1 Depth Size" Number <br /> SUMPS <br /> ❑ Distance to nearest: Well Foundation Property Lines" <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 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." Contractors hiringb r to wookmantingompensa- <br /> signatUFO <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ p 1e <br /> tion laws of California." <br /> The applica mus c r all required inspections. Complete drawing on revers e. <br /> f r .+- �:/..;`. Date: <br />! Signed X Title: <br /> t OR DEPARTMENT USE ONLY O <br /> _ Date- - v_——Area <br /> Application Accepted by, <br /> Pit or Grout Inspection by <br /> ate Final Inspection by Data lL� <br /> Additional Comments: <br /> LJ Stk 466-6781 El Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 1335-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEECK RECEIVED By DATE PERMIT'NO. <br /> INFO AMOUNT DUE A�M-O-U�NT RE11 MITTED CASH G <br /> r EH 13-24(REV.t/H61 L 0. no " �� � 47'`-2�{ <br /> EH 14-2B <br />