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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} is <br /> applicationhis is <br /> or install the work herein <br /> t a <br /> Application is hereeYNmh Sanothe)Joaquin Joaquin County OrdinalHealth nce No.District48 for sewage or permit <br /> No. 1862 forcwell pump and the Rules and Regulations of the San Joaquin <br /> made in compliant M ' <br /> Local Health District, <br /> �. BQ PM <br /> City lz " Lot Size <br /> Job Address IT�- .S/1/P lez <br /> -PA(f6 WA440 �' Phone <br /> . Owner's Name Address <br /> Contractors-+ D B <br /> �/, G No. I-A Phone —3 <br /> Address License <br /> ' <br /> WELL REPLACEMENT EI DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL 17SYSTEM ❑ OTHER 1-1PUMP INSTALLATION ElSYSTEM REP [� <br /> SEWER LINES DISPOSAL FLD. PROP. LINE e--� <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS — <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> Type of Grout <br /> Depth of Grout Seal — <br /> ❑ Delta <br /> [I Public El Other <br /> f El Irrigation --Approx. ❑ Eastern Surface Seal Installed State Work Done <br /> Repair Work Done ❑ Type of Pump H.P. <br /> Wall Destruction ❑ Well Diameter Sealing Material {top 501 <br /> Depth Filler Material {Below 50') <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION available within 200 feet.)ed if-public sewer is <br /> f / <br /> Installation will serve: Residence✓ Commercial Other <br /> Number of living units: —/— Number of bedrooms 7nf Water table depth <br /> Character.,of soil to a depth of.3-•feet:- <br /> Capacity Na. Compartments ' <br /> - <br /> SEPTIC TANK ❑ Type/Mfg <br /> r --,-a -- ";Method of Disposal <br /> PKG. TREATMENT PLT. ❑ l�X I � � � <br /> Foundation Property Line # <br /> Distance'to nearest: Well t i <br /> Total length/size <br /> LEACHING LINE- ❑ No. & Length of lines t <br /> FILTER BED ❑ Distance t rest: Well Foundation Property Line <br /> Number <br /> SEEPAGE PITS epth �lFoundation Property Line r <br /> SUMPS + ❑ Distance to ne We11 t <br /> r' <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 ou"nj+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 certifymhensation lat in the aewsoof California."Cont a toesrrnance of the work for thir ng or sub,-contracting ngpermit is issued, l signature <br /> re <br /> employ any person in such manner as to become subject to workman's ca p <br /> empl es the following:'9 certify that s o. perForrriance of fFie Work for whidfi fhis permit is'issued;I"shall`sirploy persons subject to workman's compensa- <br /> certi <br /> tion laws of California."' , i } <br /> j The applicant must call for all required inspections. C mplete drawing on reve se side. <br /> � Dater - — <br /> 922V 1 <br /> Signed Title: <br /> FOR DEPARTMENT USE ONLY <br /> Date <br /> J Area t <br /> Application Accepted by <br /> Pit or Grout Inspection by <br /> Date�-- Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466 6781 ❑ Lodi 369 3fi21 ❑ Manteca 823-7104 ❑ Tracy 835 6385 <br /> r 4 <br /> Applicant 'Return all copies to: Environmental Health Permit/Services 1fi01 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CK# RECEIVED BY <br /> FEE DATE jPERMIT'NO. <br /> AMOUNT DUE AMOUNT REMITTED +;CASHe <br /> INFO+ EH 13.24 1REV.1/e 57 � <br /> EH 14-26 _ - <br />