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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 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> ll the work herein <br /> Application is hereby made to the Sarnoun Joaquin Ordinance No.District <br /> 549 for sewage orpermit <br /> No.1862 forconstruct <br /> well//pump and the Rules and Regu�lationis of ttion is <br /> he Sed.This an r�oaqu n <br /> made in compliance with San Joaqui County <br /> Local Health District. , <br /> ' City Lot Size v PM <br /> Job Address <br /> Phone @� <br /> _a Address �\ <br /> Owner's Name <br /> License No-&ZZZ Phone <br /> CvntractoF �""1� '�"`^'CO Address �— <br /> t WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ OTHER ❑ <br /> I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> a SEWER LINES �— DISPOSAL FLD. PROP. LINE <br /> i DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> 1 <br /> r INTENDED USE TYPE OF WELL PROBLEM A`REp` CONSTRUCTION SPECIFICATIONS. Dia of Well Casing <br /> Dia. of Well Excavation <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Specifications <br /> Type of Casing <br /> T [DDomestic/Private LlGravel Pack ❑ Tracy Depth of Grout Seal Type of Grout <br /> ❑ Other ; EJ Delta <br /> ElPublic Surface,Seal installed by <br /> i 17Irriga>`ivn--,._.._.,...�.--�pprox. Depth. O Eastern__� w � State Work Done <br /> } of Pump ,- H.P. <br /> Repair Work Done ❑�. Type -- -- — <br /> Well Destruction ❑ Well Diameter, Sealing Material {top 50'1 <br /> Depth Filler Material {Below 501 -- <br /> r ;-available within 200 feet.) -� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION ❑ DESTRUCTION ❑ iNo septic system permitted if public sewer is <br /> xInstallation will serve: Residence Commercial Other�� � + z <br /> i Number of living units:�.- Number a droo s t Water table depth <br /> Character of soil to a depth of 3 feet: <br /> (Capacity l,2_0 `:< No. Compartments <br /> SEPTIC TANK Type/Mfg C _" Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Foundation Q �� Property Line <br /> Distance to nearest: Wellr � <br /> � 'r'y""'Totar le"rigttilsize <br /> p LEACHING LINE L�No. & Length of lines i <br /> Foundation�-- Property Line�3� <br /> FILTER BED [I Distance to nearest: Well (Zs2— { <br /> Size Number <br /> s SEEPAGE PITS Depth , <br /> undation.- <br /> A Fo - Property Lines — <br /> SUMPS [I Distance to nearest: WeN/fll� <br /> DISPOSAL PONDS ❑ ! <br /> L 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 /> Home owner or licensed agent's signature certifies the following: "f certify that in the performance of the work for which this permit is issued, I shall not <br /> f employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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 law"s of California." <br /> The applicant t call for r ired inspections. Complete drawing on reverse side. Date: <br /> Title: <br /> j Signed <br /> FOR DEPARTMENT USE ONLY <br /> Date JS) Area <br /> Application Accepted byA�fi Date <br /> Date Final Inspection by <br /> I Pit or Grout Inspection by + el <br /> I 11"'gteJh.. i <br /> Additiorial Comments: ❑Tracy 83x6385 <br /> ❑ Stk 1456-6781 odi 369-3621 ❑ Manteca 823-7104 <br /> Applicant - Return all copie to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009. Stk., CA 95201 <br /> s CK# PERMIT NO. <br /> CEI ED BY DATE <br /> i FEE AMOUNT DUE AMOUNT REMITTED CASH F <br /> INFO nj3 !f <br /> fes,! f <br /> + 113-241REV.k/e57 # <br /> 1 14-26 <br />