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APPLICATION FOR PERMIT <br /> SAN JOAQUIN:.LOCA"EALTH DISTRICT <br /> 1 1601 E. HAZE i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 s <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> .. ti <br /> (Complete in Triplicate) T <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is t <br /> or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage <br /> Local Health District. <br /> kt/-. City Lot Size PM <br /> Job Address _. <br /> T t rn _ Phone <br /> �Owner'sName r ��� � "`� Address k <br /> License No.a7W�Phone <br /> Contractor Address_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LJ DESTRUCTION Ll <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ <br /> SEWER LINES ��� DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS 1 <br /> I� FOUNDATION AGRICULTURE WELL OTHER WELL <br /> 4 PROBLEM AREA CONSTRUCTION'SPECIFICATIONS. <br /> SPECIFICATION <br /> INTENDED USE TYPE OF WELL Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> ;)(Domestic/Private ❑ Gravel Pack C1Tracy Type of Casing <br /> ❑ Public ❑ Other <br /> ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation �4pprox. Depth /❑ Eastern Surface Seal installed by <br /> p �/� nrf) State Work Done <br /> Repair Work Done '� Type of Pump Y H.P.-��-"'�°'—' <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material (tap 50'1 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRlADDITION ❑ DESTRUCTION LJavaiV available septic <br /> 200 feet.) if public sewer is <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: <br /> Capacity Na. Compartments <br /> j SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. Cl 1Foundation Property Pro ert Line <br /> Distance to nearest: Well <br /> I i <br /> Total length/size <br /> I LEACHING LINE L-1 No. & Length of lines Property Line <br /> FILTER,BED <br /> ❑ Distance to nearest: Well Foundation <br /> ❑ Depth r Size Number <br /> SEEPAGE PITS PropertyLirtie <br /> l SUMPS ❑ Distance to nearest: Well Foundation r <br /> I <br /> DISPOSAL,PONDS ❑ <br /> hereby certify that I have prepared this application and that the work will be done in accordance withQSn Joaquin county ordinances-state laws, and <br /> rules and tegulations 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, f signature <br /> shall not <br /> t employ any',person in such manner as to become subject to workman's compensation laws of Calrfoshaill ploy persons subject t workman'rin or s gcompensa- <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shahmploy pe I <br /> tion laws of California." } �' <br /> The applican st call for all r ired ins tions. Complete drawing on reverse side. !/ <br /> f Date: — <br /> Y� Title: <br /> Signed <br /> FOR,bEPARTMENT•USE ONLY <br /> ...-- _ � {j � Area <br /> Date A r� a . <br /> Application Accepted by rs - r <br /> t Final inspection by date <br /> ' Pit or Grout Inspecti Date <br /> , <br /> Additional Comments: <br /> f ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63$5 <br /> Applicant Return all copies to: Environmental Health'Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA.95201 <br /> 1 CK RECEIVED BY DATE PERMIT NO. <br /> FE:---;MOUNT DUE AMOUNT R ITTED CASH <br /> INF <br /> + EH 19-24(r1EV.1/05]' a <br /> EH 1428- a- - - <br />