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dao TI . . <br /> APPLICATION FOR PERMIT <br /> r�s <br /> M 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 /> s (Complete in Triplicate) <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 application is <br /> I go 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 sewa <br /> Local Health District. } <br /> F67 _ City Lot Size PM <br /> Job Address / may <br /> # V'vv <br /> Phone r <br /> Owner's Name Address <br /> I License No��Phon ��^ <br /> ' <br /> Contractors Address <br /> TYPE OF WELL/PUMP:NEW WELL ❑ WELL REPLACEMENT ❑ :, DESTRUCTION El <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. " PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> r . <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> ❑ Industrial I❑ Open Bottom ❑ Manteca Dia. of I Well Excavation <br /> Type of Casing Specifications <br /> E3 —,� <br /> ❑ Domestic/Private Gravel Pack ❑ Tracy yp g T e of Grout <br /> f`1 Public <br /> i" [1 Other P Delta Depth of Grout Seat Type <br /> I <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by <br /> H P State Work Done <br /> I Repair Work Done ❑ Type of Pump \ <br /> Well Destruction F] Well Diameter Sealing Material Itop 501 <br /> t Depth 1 Filler Material (Below 50'1 <br /> perm it <br /> TYPE OF SEPTIC WORK: NEW INBTALLATIO REPAIR/ADDITION DI STRUCTION I I (No septicaiiable sy t m feet �ed if public sewer is <br /> Installation will serve: Residence__ Commercial_K Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: <br /> Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method <br /> PKG. TREATMENT PLT. ❑ � of Disposal <br /> Distance to nearest: Well, Foundation_47-r— Property Line <br /> LEACHING LINE � No. & Length of lines d Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property tine <br /> I <br /> Numb <br /> er <br /> SEEPAGE PITS Dept` _�7 _Size <br /> SUMPS El Distance to nearest: Well Foundation 7� 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 1 <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "1 certify that in the performance r the work for which this permit is issued, I shall not <br /> laws of California." Contractor's hiring or sub contracting signature <br /> employ any person in such manner as,to become subject to workman's compensation <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 /> {ion {aws of Califor ia." <br /> ,.. r <br /> }T applicant m call for require 'ns cti o late drawing on reverse side. / <br /> Signed <br /> Title: .Date: <br /> FOR DEPARTMENT USE ONLY <br /> Date r�'3� Area <br /> Application Accepted by <br /> Pit or Grout inspection by <br /> Date. Final Inspection by Date o <br /> Additional Comments: [i ,QO <br /> ❑ Stk 4fi6 5781 ❑ L -3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2(103. Stk., CA 95201 <br /> FEE flRECEIVED BY DATE PERMI7�NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED <br /> ♦ EH 13.24 04ty.r/n 5) �� <br /> EH 1426 <br />