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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 /> Appi <br /> t and/or install the work <br /> cation is <br /> madlec nt'compliance wiieby th Sanade toJoaquinthe SanCouJoamy ordinance uin lHealth District for a No.549 for sewage or permit <br /> No. 1862 forcwell//pump and the Rules and herein <br /> R gulations of the San Joaquin <br /> Local Health District. .-/�O� �� <br /> B �7.-4 AS PM <br /> Job Address—, �j� "" " X City�,���1 Lot Size <br /> Owner's Name T — Address 4992 N� �F �/Q� Phone ' <br /> Address S License No.37�' Phone <br /> Contractor <br /> TYPE OF WELL/PUMP: NEW WELL D5- WELL REPLACEMENT 1:1DESTRUCTION E3 \ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO�— PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' <br /> Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing Specifications <br /> 'Domestic/Private �CGravel Pack C1 Tracy g�� � � fq Rpt / N/r <br /> FI Public n Other tl <br /> � Depth of Grout Seal l��) Type of Grout <br /> I I Irrigation 0wrox. Depth Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 — <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> C <br /> SEPTIC TANK El Type/Mfg apacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> `LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size — Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <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, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I <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: " ertify 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 app i a t ca for all a uired inspections. Complete drawing on r v rse side. <br /> Signed <br /> Title: Date: <br /> FOR DEPARTMENT USE LY <br /> Date rea <br /> Application Accepted <br /> ,� 0 <br /> Pit or Grout Ins by <br /> Date Final Inspection Dat <br /> Additional Co ts: — <br /> ❑ Stk 466-6 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83 6385 <br /> Applicant - Ret s to: Environmental fealth Permit/Seolces,l E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE U T REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> . EH 1324(REV.1/N 5) ��'V t) <br /> EH 1128 <br />