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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 TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> /or install the work <br /> n describe . This <br /> cation is <br /> made ntcomp lance with SanJoaqu nn CouJoanty Ordinance No. 549 for sewage or permit <br /> 1862 for cwellldpump and the Rules and IR gulations of the Sang Joaquin <br /> Local Health District. <br /> Job Address City �Akkq Lot Size <br /> PM <br /> Fid �i9%Iaa- <br /> Phone <br /> Owner's Name. <br /> �" Address # <br /> Contractor l� Address . —License No ln'>_f�S'Si:2-Phone <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ I <br /> TYPE OF WELL/PUMP: NEW WELL ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ industrial El Open Bottom ❑ Manteca Dia. of Wel! Excavapia. of Well Casingtion , <br /> Type of Casing Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy YP g <br /> M Public Ll Other 171Delta Depth of Grout Seal Type of Grout <br /> -�}s <br /> I I Irrigation —.-Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done— L7 Type.of-P__ump._- --«R- H.R. -"-, State Work Done <br /> Well Destruction ElWell Diameter Sealing Material (top 50'1 <br /> Depth Filler Material (Below 501 <br /> e TYPE OF.SEPTIC WORK--NEW-9NSTALLATION�1':I'-REP)4IRi7kuDITtON l i DESTRUCTIO (No septic system permitted if public sewer is <br /> r 2 available within 200 feet <br /> Installation will fere-:- R#§1d6_t ce"=-Commercial" `Other <br /> Number of living units: '~ Number of bedrooms I <br /> Character of soil to a depth of 3 feet: r Water table depth <br /> SEPTIC TAMC ❑ Type/Mfg Capatcity No. Compartments <br /> PKG. TREATMENT PLT. ❑,;,.ori � .4.„v-. „3 4 <br /> Method of Disposal <br /> Distance to nearest: Well r 'Foundation Property Line <br /> e <br /> r <br /> LEACHING LINE ' i C1 No. & Length of lines Total lengthlsize <br /> k FILTER BED ❑ Distance to nearest: Well 'Foundation 'Property line <br /> SEEPAGE PITS 1 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well `>"� ";Foundation _ ,� Property Line <br /> DISPOSAL PONDS f D t <br /> f 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 Sart Joaquin Local Health District. Ig t <br /> p 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, 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 /> certifies the following: 'I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California:",.--" �'- ; <br /> The applicant must call for all required ins ions. Complete drawing on reverse side. <br /> Date: 5-5r <br /> 5'5 <br /> Signed Title: 42 <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> i Date r Area <br /> IC� Date <br /> Pit or Grout inspection by Data Finalanspection by <br /> i 10ir <br /> I Additional Comments: <br /> ❑ Stk 466-6781 1 ❑ 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 AMOUNT REMITTED C SH �4 RECEIVED BY X, DATE <br /> DATE PERMIT NO. <br /> INFO <br /> 'r EH 13-24IREV.1/851 <br /> EH 14-28 <br />