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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL ION.AVE.,,.STOCKTON, CA <br /> -Telephone (209) 466-6781 V. <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> �c (Complete in Triplicate),.,,,w. <br /> fO:` Taj- :x., '. ation is <br /> .- <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This applic4 <br /> e or No. 1862 for well/ and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance.No.549 for sewag4 <br /> Local Health District. <br /> xr" JLot Size PM <br /> 06? " City <br /> Job Address a , <br /> ` r <br /> 1 <br /> Address 76 .Phone <br /> Owner's Name 2 <br /> 1 a Phone_• / <br /> Contractor <br /> ress License No. <br /> TYPE OF ELL/PUMP: . NE WELL ❑ WELL REPLACEMENT ❑ _ Rq DES T UCTION ❑ (1 <br /> PUMP INSTALLATION ❑ SYSTEM( REPAIR ❑ OTHER ❑ <br /> Lu" °DISPOSALIFLD. t PROP. LINE_ J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES .r —" <br /> �'" THER"WELL `� ^ PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL -. � � <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 1r Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation r,t 1 <br /> i ' T e"of Casing <br /> `iSpecifications <br /> i ❑ Domestic/Private ❑ Gravel Pack El Tracy yP a <br /> ❑ Public <br /> ❑ Other ❑ Delta Depth,of Grout Seal TypeofGrout <br /> ❑ Irrigation �4pPro i, Depth ❑ Eastern Surface Seal Installed by <br /> r H P State Work Done <br /> Repair Work Done LD Type of Pump <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Filler Material (Below 50'1 k' ' <br /> Depth 4,s ,"' <br /> TYPE OF SEPTIC WORK: NEW INSI LELATION ❑• EPAIR JADDITION ❑ DESTRUCT,ION availabllelw thin 200 feetit.) if public s <br /> Installation,will serve: Residence! Commercial— rOther <br /> Number oflivingunits: � Number of bedrooms—�2— I <br /> I Water table depth <br /> Character of soil to a depth of 3 feet: 1 <br /> Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> r PKG. TREATMENT PLT. ❑ r <br /> Distance to nearest: Well �6 Foundation� �Property Line <br /> LEACHING LINE ❑ No. &"Length of lines <br /> " " c f" i Total'length/size <br /> I FILTER BED ❑ Distance to nearest: Foundation Prope�Le <br /> .,m t I J <br /> Size .` Number <br /> SEEPAGE PITS ❑ Depth <br /> r Distance to nearest: r We11 _ Foundation Property Line <br /> SUMPS" -. r <br /> DISPOSAL PONDS ❑ _. - "` <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county <br /> hordinances, 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: "I certify that in the performance of the work for which this permit is issued, l shall not <br /> employ any person in such manner as to become subject to workman's compensation taws of California." Contractor's hiringo to -conworkan'tr Iscompensa <br /> i certifies the following:"1 certify that in the performance of the work for which.this permit is issued, I shall employ psubject <br /> tion laws of California." <br /> The applic mu c for all re "e inspections. Complete drawing on reverse side. <br /> A Date: <br /> Signed � ^ Title:, <br /> FOR DEPARTM NT USE ONLY <br /> �" 0'�. <br /> Date <br /> Application Accepted by <br /> r Final Inspection by Date <br /> Pit or Grout Inspection by D @ /99� <br /> Additional Comments: c <br /> ❑ Stk 466-6781 .❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385" <br /> I Applicant - Return all copies to: Environmental Health Permit/Services 1601E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE 'AMOUNT DUE 4- AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> + EH 13-24 IR1::V: INFO iiR s� - <br /> EH 14-28 <br />