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APPLICATION FOR PERMIT <br /> i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA r <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> qDistrict for a permit to construct and/or install the work herein described. This application is <br /> Application is hereby made to the San Joaquin Local Health <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. . <br /> (� City Lot Size PM <br /> f1 Job Address y <br /> Phone <br /> Owner's Name F Y Address <br /> Contractor <br /> Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION LJ <br /> PUMP INSTALLATION EJ I <br /> SYSTEM REPAIR ❑ OTHER L1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PiTSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia.1of Well Casing <br /> ❑ industrial ❑ Open Bottom C3 Manteca Dia. of Well Excavation <br /> Specifications <br /> ❑ Domestic lPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Type of Grout <br /> (`l Public ❑ Other 1 C-1DeltaDepth of Grout Seal <br /> I l Irrigation �_Approx. Depth I 1 Eastern i-Surface Seal Installed by} o + I H P State Work Done <br /> [3 — <br /> Repair Work Done Type of Pump x <br /> .Sealing Material (top 50'1 <br /> Well Destruction ❑ Wel! Diameter g i I 1 <br /> Depth t 'Filler Material (Below 501 <br /> I <br /> TYPE OF SEPTIG.VI CIRK: NEW INSTALLATION I:I REPAIRIADbhTION lY I, DESTRUCTION alvailabPerw bin 206 feet.) <br /> ed it public sewer is <br /> AInstallation will'serve: Residence Commercial_�t Other .N. f <br /> i <br /> { <br /> k Number of living units: Number of bedrooms Water table depth <br /> i <br /> Character of soil to a depth of 3 feet:! No. Compartments <br /> SEPTIC TANK ElType/Mfg Capacity <br /> 1 I i Method of Disposal <br /> f PKG. TREATMENT PLT. 0 } <br /> Distance to nearest: Well Foundation Property Line <br /> I V i <br /> LEACHING LINE G Na. & Length of lines <br /> I #Total length/size P <br /> FILTER BED ❑ Distance,to nearest: Well Foundation Property Line <br /> I <br /> SEEPAGE PITS ( I Depth <br /> Size Number <br /> SUMPS ❑ Distance rto nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ .! <br /> i <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 signatsignature <br /> ure certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> I - <br /> employ any person in such manner as to become subject to workman's compensation laws of California." ContraceQsons1sub'ect to woring or �kman'jscompensa- <br /> certifies the following: "1 certify that in the performance of the work for which this permit is issued,I shall employ p 1 <br /> tion laws of California." <br /> i The applicant call for require inspections. Complete drawing on reverse side.pp �� – <br /> Title: cr— Date: ��' r <br /> Signed X !�& _ <br /> FOR DEPARTMENT USE ONLY <br /> Date Z Area I I <br /> Application Accepted by <br /> Date Final Inspection by Date <br /> Pit or Grout Inspection by <br /> Additional Comments: <br /> ❑ Silk 466-6781 ❑ Lodi -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, Sik., CA 95201 <br /> r{I CK RECEIVED BYHDTE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> r INFO <br /> a.EH 13-24 I REv.1�rs s i <br /> I "y <br /> EH 14-26 <br />