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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601'E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466.6781 <br /> PERMIT EXPIRES 1YEAR FROM DATE ISSUED <br /> A >r <br /> (Complete in Triplicate) <br /> I Application is hereby made to the San Joaquin Local Health District fora _ <br /> made H compliance with San Joaquin County Ordinance No.549 for sewage No. 1$62 forcwell pandlump and l the Rules and Regulatiorls of the Sa <br /> Loco! Health District. or described. This application is <br /> San Joaquin <br /> Joh Address <br /> City Lot Size <br /> Owner's Name PM <br /> ddress � D <br /> Contractor Phone <br /> Address �nn / Q ` <br /> TYPE OF WELL/PUMP: N W WELL ❑ cense No I Phone p <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> .;, PUMP INSTALLATION 11::: <br /> DISTANCE TO NEAREST:'SEPTIC TANK SYSTEM REPAIR ❑ OTHER ❑ <br /> SEWER LINES — DISPOSAL FLD, i <br /> FOUNDATION AGRICULTURE WELL PROP. LINE <br /> INTENDED USE i TYPE OF WELL OTHER WELL PITS/SUMPS <br /> PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom' ~ <br /> ❑ Manteca Dia. of Well Excavation a � <br /> Domestic/Private ❑ Gravel Pack Dia. of Well Casing <br /> ❑ Public ❑ Tracy Type of Casing <br /> ❑ Other ❑ Delta Depth of Grout Seal Specifications <br /> ❑ Irrigation ---Approx. Depth Eastern Type of Grout <br /> Repair Work Done ❑ T Surface Seal Installed by r <br /> Type of Pump, H.P. , <br /> Wel! Destruction ❑ ..i Wel! Diameter S to Work one <br /> Sealing Material (top 50') <br /> TYPE <br /> .Depth Filler Material (Below 501) ' <br /> OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIO11 N ❑ DE11 STRUCTION ❑ fNo septic system permitted rf ublic <br /> Installation will serve: av p sewer is <br /> Residence! Commercial ailable within 200 feet.) <br /> Number of livingunits: — Other , <br /> Number of bedrooms � <br /> Character of soil to a depth of 3 feet: `. <br /> SEPTIC TANK Water table depth <br /> ❑ Type/Mfg <br /> PKG. TREATMENT PLT. ❑ Capacity���_ No. Compartments <br /> Distance to nearest: Well Method of Disposal <br /> Foundation property_ Line, <br /> LEACHING LINE ❑ No. & Length of lines -� <br /> FILTER BED ❑ Distance to nearest'" Well' Total length/size <br /> ' � Foundation <br /> Property Line <br /> SEEPAGE PITS ❑ Depth <br /> SUMPS Size Number <br /> ❑ Distance to nearest: Well <br /> DISPOSAL PONDS ❑ Foundation�� property Line <br /> 1 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 s <br /> rules and regulations of the San Joaquin Local Health District. 4 <br /> Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this <br /> employ any person in such manner as to become subject to workman's compensation <br /> certifies the person <br /> Permit is issued, I shall not ' <br /> following: "I certify that in the performance of the work for which ethis per laws of Cd, I shall r Contractor's hiring or sub contracting signature <br /> tion laws of California." permit is issued, I shall employ persons subject to workman's com <br /> The applicant ust call or all required ins Comppensa <br /> pe ions. lete drawing on reverse sioe. <br /> Signed <br /> Title: <br /> Data: <br /> ` DEPARTMENT USE ONLY <br /> Application Accepted by C <br /> �� t <br /> Pit or Grout Inspection by Date Area <br /> Date— Final Inspection bbl fn'\ 1r7 L_ <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 CK# <br /> INFp AMOUNT REMITTED RECEIVED BY �) r <br /> CASH DATE PERMIT`No. <br />+EH 13-24(REV.t/a 51 S _ /} <br /> EH 14-26 !r`1 JKC.� <br /> et'l ( !?19-3 915 <br />