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APPLICATION FOR PERMIT L� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE I ON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 e <br /> PERMIT EXPIRES 1 YEAR.FROM DATE ISSUED <br /> 4(Complete in Triplicate) <br /> w r No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> App lica <br /> tion is hereby made to the San Joaquin Local Health District sBwa9e o it to construct <br /> and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance o <br /> Yv <br /> Local Health'District.. 0: F - PM <br /> i ` r City S L'� Lot Size <br /> Job Address E 0 y« <br /> ` L o Phone <br /> ✓ S �&9 Address. ¢ <br /> Owner's Name '' r <br /> License No. Phone <br /> Address -- <br /> Contractor WELL REPLACEMENT ❑ DESTRUCTION'❑ <br /> :•NFW WELL❑� OTHER 13TYPE OF WELLIPUMP:.. �--•---' <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR IJD.—FLD.. PROP. LINE <br /> SEWER LINES —�� P{TSlSUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK �— AGRICULTURE WELL OTHER WELL�� <br /> r FOUNDATION <br /> INTENDED USE TYPE;OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> Open Bottom ❑ Manteca Dia- of Well Excavation <br /> ❑ Industrial ❑.Op Specifications <br /> ❑ Gravel Pack ❑ Tracy Type of Casing Type of Grout <br /> I ❑ Public Domestic/Private Depth of Grout Seal <br /> El Other L] Delta — 0 <br /> I <br /> F] Public :. Surface Seal Installed by <br /> ❑ Irrigation ---Approx. Depth (7 Eastern H.P. State Work Done <br /> �— <br /> Repair Work Done EJ Type Pump Type Sealing Material {top 501 <br /> Well Destruction ❑ Well Diameter Filler Material (Below 50') <br /> Depth <br /> F ailable within 200 feet.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRlADD1TION ❑ DESTRUCTION (No septic system permitted if pubic sewer is <br /> ' Installation will serve: Residence Commercialx Other <br /> r <br /> Number of living units: Number of bes Water table depth <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg ✓, _,��-r Method of Disposal <br /> PKG. TREATMENT PLT-fl ! Line <br /> Distance to nearest: Well Foundation Property <br /> 1 <br /> I � <br /> - 3 a Total length/size <br /> LEACHING LINE ❑ No- & Length of lines Property Line <br /> FILTER BED <br /> ❑ Distance to nearest: Well Foundation t <br /> SEEPAGE PITS ❑ Depth Size <br /> Number <br /> I <br /> SUMPS ❑ Distance to nearest: Well ° Foundation Property Line <br /> i <br /> DISPOSAL PONDS El ` <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, a <br /> rules and regulations of the San Joaquin,-Local-Health District. <br /> Home owner o lone n such manner as to become subjecttoworkman'scertify <br /> compen ation laws of California." Contractor's rmance of the work for rhui hiring or sub-contracting l signlatuot <br /> employ y Pe <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman s compen <br /> tion laws of California." <br /> The applicant must call for II required 4 i spections. Complete drawing on reverse side. <br /> Title: Date: < <br /> iSigned X_�/�?'J7 .' — <br /> FOR DEPART T USE O Y <br /> Area Q 3 <br /> 7 ate <br /> Application Accepted by �A <br /> Final In <br /> by (� Date <br /> Pit or Grout Inspection by Date <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 95241 <br /> nINFO <br /> AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT•NO.+ EH 13-24inEv. <br /> EH 1429 <br />