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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> " 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone {209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> i (Complete in Triplicate) ork <br /> cation is <br /> Application is ewmade <br /> h SanoJoaqu nSan <br /> Counguln ty Ordinance No.549 for sewage or Health District for a permit <br /> No. IB62 for wellland/or <br /> pumlp and the Rules and herein <br /> Regulations of tlhe Sanis s Joaquin <br /> al[the w <br /> made in compliance <br /> Local Health District. <br /> �! Lot Size ���e PM <br /> City <br /> Job Address <br /> Phone <br /> Owner's Name Address ��}} (f <br /> ?ed (Ad t/d License No. OAA Phone T1 <br /> Contractor 1+f I' l Address <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUGTION D <br /> PUMP INSTALLATION El SYSTEM SYSTEM REPAIR OTHER ❑ <br /> ® DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES __��— d f PITS/ <br /> �Y"FOUNDATION •' AG8ICULTURE WELL.m—....� OTHE�i-WELL_ � <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Oen Bottom ❑ Manteca -• •Dia. of Well„Excavation i <br /> Cl Industrial P - Z` + Specifications <br /> T `e•of..Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy YP Type of Grout <br /> Cl Other it C1 Delta €Depth of Grout Seal <br /> t`l Public V" <br /> _..Approx. Depth I 1 Eastern / Surface Seal Installed by J. <br /> s I ! i�ngatian r State Work Done <br /> Type of Pi��] <br /> mH P <br /> Repair;Work Done ❑ Typ <br /> Sealing Material (top 50'1 �cc� <br /> Well Destruction Well Dt Filler Material IBelow 50'1 <br /> Depth0. <br /> `TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION Imo! DESTNo <br /> RUCTION l i a aiiabNo pelwithin 200 feetc system itled it public sewer is <br /> SwJ <br /> Installation will serve: Residence Commercial 4 e,Other <br /> j Number of living units: Number of bedrooms Water table depth <br /> 6 Character of soil to a depth of 3 feet: <br /> � Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg - Method of Disposal <br /> E PKG. TREATMENT PLT. ❑ ^-- t ti %. '4 <br /> ! 'r� Pro art Line <br /> Distance to nearest: t Well Foundation P Y <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines ^ Property Line <br /> FILTER SED [I Distance to nearest: Well Foundation P Y <br /> --a—a <br /> Number <br /> SEEPAGE PITS I I Depth Size Property Line <br /> SUMPS L] Distance to nearest: Well Foundation p Y <br /> F DISPOSAL PONDS ❑ <br /> 1 Y <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 Di§trict. <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 C <br /> The applica m t call for all require specti Complete dra g on reverse side. � 1 <br /> itle: Date: r <br /> Signed X <br /> FOR DEPARTMENT ME <br /> ONLY <br /> r <br /> DAby <br /> Area <br /> Application Accepted by g� <br /> Pit or Grout Inspection by <br /> Date Final Inspection Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 L3 Lodi 369-3621 CI 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 /> t <br /> FEE CK RECEIVEQ tiY QATE PERMIT'NO. <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO {� Q—l� 2 �� 72- <br /> EH 13-24(REV. <br /> �p `p � <br /> EH 14-26 - <br />