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4001ICATION FOR PERMIT <br /> SAN JOA¢UIN`LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL ON AVE., .STOCKTON, CA <br /> Telephone {209) 4,66-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1.413L, " (Complete in Triplicate) <br /> ll the work herein <br /> ed, This <br /> cation'is <br /> Application ade ,hereby wimade th Sano the San Joaqu n oounty ordinance quin l �No.Districtlth 549 for sewage or't to No. 1862 forcwell/Pump and the Rules and Regu�latior of the San'Joaquin <br /> made in compliancel <br /> ,ol Local Health District. Y1 <br /> +'All.. City" of Size PM <br /> Job Address w <br /> J -^-� - Phone Z <br /> Owner's Name-_ ddress <br /> x License Phone 6 62 <br /> Contractor "`•� Address <br /> WELL. ❑ DESTRUCTIO <br /> TYPE OF WELL/PUMP: ` NEW WELL ❑ OTHER ❑ <br /> PUMP'INSTALLATION ❑ 'SYSTEM REPAIR ❑ <br /> f 1 1. DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES OTHER WELL PITSISUMPS <br /> FOUNDATION `' AGRICULTURE WELL <br /> INTENDED_'USE TYPE OF WELLPROBLEMAREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ Industrial` ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Specifications <br /> Type of Casing fications <br /> ❑ Domestic/Private 1-1GravelPack ❑ TracY �� Depth of Grout Seal Type of Grout <br /> i` ❑ Public Ll Other ❑ Deltas <br /> ❑ Irrigation <br /> ---Approx. Depth El Eastern f Surface Seal Installed by <br /> H P 3_ State Work Done <br /> Repair Work Done ❑ Type of Pump ' <br /> Ce en <br /> 4' 11Sealing Material ttop 501 <br /> 4 Well Destruction �O'Well Diameter <br /> Depth Filler Material (Below 50') <br /> c' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> Val a-1 within 200 feet.) <br /> F Installation will serve: Residence— Comme clal, Other .- <br /> Number of living units: Number of bedrooms Ty Water table depth <br /> F Character of soil to a depth of 3 feet: <br /> g <br /> ❑ Type/Mf Capacity No. Compartments <br /> SEPTIC TANK Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: ell Foundation <br /> rf�" <br /> .� Total length/size <br /> LEACHING LINE ❑ No. & Length ines Property Line <br /> ' FILTER BED 171Distance o nearest: Well Foundation p rtl <br /> SEEPAGE PITS ❑ Depth <br /> k <br /> size Number <br /> t <br /> SUMPS Q'l"Distance to nearest: Well" Foun tion roperty Line <br /> DISPOSAL PONDS <br /> 1 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 /> 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 uch manner as to become subject to workman's compensation laws of California.';_Contractor's hiring or sub-contracting signature <br /> certifies t fallowing: certify t n the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa <br /> tion law of California." <br /> The app cant m t re ire <br /> inspe tions. Complete drawing6se si e. <br /> TitleL,' Date: <br /> Signed •- <br /> f FOR DEPARTMENT USE ONLY , <br /> s •�� r � Date� Area <br /> Application Acceptedby y w <br /> Pit or Grout Inspectio Date <br /> Applicant Return all copies to: Environmental Hesli ' ! <br /> .Final Inspection by Date 7 <br /> Additional Comments: <br /> ❑ Stk -466-6781 El Lodi 369-3821 ❑ Manteca $23.7104 © Tracy 835-�85 <br /> h Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> ` CK RECEIVED BY DATE PERMIT NO. <br /> t FEE AMOUNT DUE AMOUNT REMITTED CASH �f <br /> INFO <br /> + EH 13-24(REV.t <br /> EH 14-28 - - <br />