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APPLICATION FOR PERMIT <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) �t . <br /> Application is hereby made to the San Joaquin Local 1.Health District for a permit to construct and/or install the work herein described. This application is <br /> or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage <br /> Local Health District. <br /> Job Address City Lot Size k PM <br /> JIB.-�]� Phone 2 <br /> Owner's Name — f Address w� ` <br /> Contractor ��� Address License No:Z(P '121-Phone '- <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPL CEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR1' 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 `P-V <br /> 1:1Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing d <br /> ..L;a Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other i ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. De th ❑ Eastern Surface Seal Installed by ' <br /> H <br /> p dj+; { <br /> Repair Work Done ZType of Pump', }}r� H.P. tate Work Dne <br /> Well Destruction ❑ Well Diameter - --- `"Sealing-Material-Itop-50''1a^�­ !H'� <br /> Depth Filler Material (Be1ow 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/,ADDITION ❑`t DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> 4 available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other 's_ <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK _ ❑ Type/Mfg f Capacity No. Compartments <br /> PKG. TREATMENT PLT: ❑ :Met.hod of Disposal <br /> i 1 <br /> _3 .. � <br /> Distance to nearest: Well Foundation Property Line <br /> � A: <br /> LEACHING LINE ❑ No. & Length of lines Total length7size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property`Line <br /> SEEPAGE PITS ❑ Depth ' Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line . 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 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 parsons subject to workman's compensa- <br /> tion laws of California." <br /> The applican�mut all far a aired inspections. Complete drawing on reverse side. / <br /> Signed K <br /> { Title: Date: V <br /> FO�DEPARTMPT USE ONLY <br /> Application Accepted by � klInspecti date ' Ac reaNPit or Grout Inspection by Date Fon by r �� ,Date <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. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE . AMOUNT REMITTED LICK <br /> # RECEIVED BY DATE PERMIT"N0. <br /> INFO <br /> +EH 53-24(REV.)/851 �S 'C'C' <br /> EH 14-26 <br />