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13: 00 <br />APPLICATION FOR PERMIT <br />Yr - <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZELTON AVE., STOCKTON, CA <br />Telephone (209) 466-6781 <br />PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br />Complete in Triplicate) <br />of install the work herein This cation is <br />made <br />inion <br />is <br />compliance with <br />Sanothe <br />Joaqu n County Ordinance <br />uin llNo.549 for sewage or <br />ealth District for a permitNo. 1862 for welUpump and the Rules and Regulations of the San'Joaquin <br />Local Health District. <br />Li City Lot Size PM <br />Job Address <br />Address <br />Phone. <br />Owner's Name <br />Contractor dress License No.Phone <br />TYPE OF WELL PUM NEW WELL WELL REPLACEME DESTRUCTION <br />PUMP INSTALLATION SYSTEM REPAIR OTHER <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES IDISPOSAL FLD. PROP. LINE <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />Industrial LJ Open Bottom Manteca Dia. of Wel{ Excavation Dia. of Well Casing <br />0 Domestic/Private Gravel Pack Type of Casingg <br />Specifications <br />t"1 Public Other n Delta Depth of Grout Seal Type of Grout <br />k I Irrigation Approx. Depth 1 I Eastern Surface Seal Installed by <br />Repair Work Done Type of Pump H.P. State Work Done <br />Sealing Material (to 50'1 <br />i <br />Well Destruction Well Diameter 9 p <br />Depth Filler Material (Belo <br />i <br />TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION IQFSTRUCTION [ I (No septic system permitted if public sewer is <br />f i <br />available within 200 feet-1 <br />Installation will serve: Residence_ Commercial— Other <br />Number of living units: —,V— Number of bedrooms Ir i <br />Character of soil to a depth of 3 feet: <br />Water table depth <br />Capacity <br />t No. Compartments <br />SEPTIC TANK Type/Mfg <br />PKG. TREATMENT PLT. <br />Method of Disposal <br />Distance to neatest: Well Foundation I Property Line <br />I EACHI;111'41F LINE No. & <br />LengthoflinesTotal length/size <br />FBED Distance to nearest: Well Foundation Property tine t <br />tti "v <br />AGE r I 1.-Depth Size Number <br />SUMPS Distance to nearest: Well-J' Foundation Property Line_ <br />DISPOSAL PONDS <br />I 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 />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 t c r req a nspections. Co late drawing an re s side. <br />Signed X <br />y <br />Title: Date: - <br />F DEPARTMENT USE ONLY <br />Date Area <br />Application Accepted by ` <br />I Pit or Gr'oui Inspection by r. Date Final inspection by Data <br />i t <br />6 <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. Bax 2009, Stk., CA 95201 <br />FEE AMOUNT DUE AMOUNT REMITTED CASH <br />RECEIVE[? BY DATE PERMIT NO. <br />s.EH 13-24(REV.I H5) <br />INFO <br />0 <br />j 24 <br />EH 14-2a