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APPLICATION FOR PERMIT <br /> t ' A SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> li 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I I (Complete in Triplicate) <br /> s i <br /> 1862 for welll <br /> Application is hereb made to the San Joaquin Local Health District for a permit to construct install the work herein described. This application n <br /> made in compliance,wth San Joaquin County Ordinance No.549 for sewage or No. ll/pu pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> City Lot Size PM <br /> Job AddressSm - <br /> i��. �f/Id ///v�yC/�Address " - ve— Phone 6 7� <br /> Owner's Name Q <br /> License No.� Phone <br /> Contractor ��`'� 1 Address <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELL/POMP: SYSTEM REPAIR ❑ OTHER ❑ <br />�� I PUMP INSTALLATION OS PROP. LINE <br /> SEWER LINES 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL HER WELL— <br /> FOUNDATION 1 <br /> •. il�; . FOUNDATION , <br /> TYPE OF WELL PROBLEM AREA i C UCTION SPECIFICATIONS <br /> INTENDED USIE pia. of Well Casing <br /> ❑ Industrial r` ❑ OPon BotteiTi" ❑ Manteca 'Dia. of Well Excavatio Specifications <br /> t ' P Type of Casing <br /> ❑ Domestic!Private El Gravel Pack ❑ y { Depth of Grout Seal Type of Grout <br /> ' �} ❑ Other ❑ Delta <br /> r+l;l Public r - <br /> Ip Depth I i Eastern Surface Seal Installed by <br /> + I i laigation — State Work.Done _ <br /> l i.. a of Pump H.P. 1,1 <br /> Repair`Work Done yp <br /> + Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material {Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DES TRUCTION aNailabpe{within 200'settled if public sewer is (\ <br /> Installation will'sme: 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 /> SEPTIC TANK III; K Type/Mfg <br /> Capacity`�'� No. Comjiartments <br /> I Method of Disposal <br /> PKG. TREATME., T PLT. ❑ Property Line <br /> Distance to nearest: Well Foundation <br /> Total_lengt size <br /> LEACHING LINEA ❑ No. & Length of lines - • - - 1� <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line - <br /> Size Number <br /> SEEPAGE PITS '' I I Depth' prpperty Line <br /> SUMPS '1 ❑ Distance to nearest: Well Foundation <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 /> i Home owner or�licansed 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."Contractor's hiring or sub contracting signature <br /> ject to <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subworkman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on revL side <br /> Title: <br /> / 1l Date:—_ry <br /> Signed <br /> FOR DEPARTMENT USE ONLY <br /> I Date �~ Area <br /> Application Accepted by <br /> Ip Date Final Inspection by Dat c } <br /> Pit or Grout Inspection <br /> f Additional Co IFments: <br /> r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 C1 Tracy 835-6385 <br /> rmiilServices 1601 E. Hazelton Ave., PA. Box 2009, Stk., CA 85201 <br /> Applicant - Ret`urn all copies to: Environmental Health Pe <br /> IIF. <br /> t <br /> INFO RECEIVED BY DATE PERMIT NO. <br /> 5 FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> F + EH 13-24(REV.t/A 5 <br /> EH 14-2a <br />