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,w <br /> APPLICATION FOR (PERMIT <br /> SAN JOAaUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL I ON AVE., STOCKTON, CA ti <br /> (!: Telephone (209) 466-6781 <br /> `(PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) - <br /> lcation is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. this application is <br /> Appi <br /> made in compliance with San Joaquin Co unty Ordinance No.549 for sewage or No. 1862 far welt!pump and the Rules and Regulations of the San Joaquin <br /> Local Health District <br /> City <br /> Lot Size PM <br /> Job AddressC6 `—�L <br /> Address <br /> Phone <br /> Owner's Name <br /> Contractor �—� �-- Address <br /> License No.� Phone <br /> TYPE OF WELL/PUMP: NEW WELL 7-1WELLREPLACEMENT LiDESTRUCTION El <br /> SYSTEM REPAIR ❑ OTHER <br /> 'PUMP INSTALLATION ❑ <br /> ID <br /> SEWER LINES DISPOSAL FLD. w PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL— <br /> INTENDED <br /> FOUNDATION AGRICULTURE WELL . <br /> INTENDED USE .TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> C1 Industrial Type of Casing Specifications <br /> ❑ Domestic/Private ❑ Gravel Pak ❑ Tracy Depth of Grout Seal Type of Grout I <br /> Public � Cl Other ❑ Delta <br /> AI <br /> Depth 1 1 Eastern Surface Seal installed by <br /> I 1 Irrigation — ppro.rH.P. State Work Done <br /> Repair Work Done ❑ Type of Pump <br /> Sealing Material (top 50'1 <br /> Well Destruction El Well Diameter _ <br /> Depth j Filler Material iBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITION I i DESTRUCTION aNailabPerwthine200 feetrtMed if public sewer is <br /> Installation will serve: Residence F Commercial_ Other <br /> r Number of living units: Number of bedrooms Water table depth <br /> l Character of soil to a depth of 3 feet: Capacity No. Compartments <br /> tt SEPTIC TANK ❑ Type/Mfg <br /> .� Method of Disposal <br /> PKG. TREATMENT PLT. ❑ I Property Line <br /> Distance to nearest: Well Foundation p Y <br /> 'r <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Property Line <br /> FILTER BED ❑ Distance to nearest: Well Foundation P Y <br /> I <br /> Number <br /> SEEPAGE PITS V I Depth.j Size - Foundation Property Line <br /> SUMPS Ll Distance to nearest: Well <br /> DISPOSAL PONDS ❑ <br /> 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, an <br /> rules and regulations of the San Joaquin Local Health District.,..- - <br /> Home owner or licensed agent's signature certifies the following: ' certify that in the performance of the work for which this permit is issued, I shall not <br /> 9 <br /> uto become subject to workman's compensation laws of California." Contractor' <br /> employ any person in such manner as this s hiring or sub contracting signature <br /> I ce of the work for which s permit is issued,I.shall employ persons subject to workman's compensa- <br /> certifies the following: certify that in the performan <br /> tion laws of California." i¢ <br /> k The applicant must call for ail req 'red inspectio . Complete drawing on reverse side. 4 <br /> cs v� <br /> Title: Date: `tom <br /> Signed ) <br /> FOR DEPARTMENT USE ONLY <br /> - <br /> Data <br /> `\ Area <br /> Application Accepted by <br /> i ' Final Inspection by Date <br /> Pit or Grout Inspection by Date <br /> Additional Comments: <br /> ElStk 466-6781 ❑ Lodi 369-3621 El Manta 823 7104 ❑ Tracy 835 6385 <br /> Applicant - Return all copies to: Erivironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 <br /> . r <br /> p FEE AMOUNT DUE AMOUNT REMITTED ASW RECEIVED By DATE PERMITNO. <br /> INFO <br /> � I-22 <br /> +-EH 13-24 iREV,t i H s7 <br /> EH 14-28 <br />