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APPLICATION FOR PERMIT <br /> � � . <br /> SAN JOAaUIN LOCAL HEALTH DISTRICT i <br /> 1601 E. HAZEL—ION AVE., STOCKTON, CA �� <br /> Telephone,:(209) 466-6781 . 1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) ENVIROMENTAL HEALTH <br /> l <br /> is <br /> Application is hereby made to the San Joaquin Local <br /> No.Health <br /> District <br /> it t construct for well pump and the Rules a R�agulalt�ioru o�VQthe ilI Joaquin <br /> and/or n <br /> made in compliance with San Joaquin County Ordinance � . � for sewage or }, <br /> Local Health District: rnl t, x <br /> PM <br /> 33 ,C r city Lot size <br /> Job Address '' - - <br /> 40 1 <br /> {� Q dress Phone <br /> 41, <br /> Owner's Name <br /> t- - Phone <br /> Contractor Address / u����B�License No. - <br /> TYPE OF WELL/PUMP: NEW WELL Q WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> G YSTEM REPAIR ❑ OTHER ❑ <br /> PUMP I 5 ALLATION M R DISPOSAL FLD. PROP. LINE <br /> SEWER LINES <br /> DISTANCE TO NEAREST: SEPTIC TANK fff"' <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �r� <br /> --�- `� Dia. of Well Casing <br /> ❑ Industrial - •EI-Operl-Bottom--❑-Manteca'� 131:of 1Nell'Excava'tion Specifications <br /> ❑ Tracy �'TYpe of Casing <br /> Domestic/Private ❑ Gravel Pack Depth of Grout Seal Type of Grout <br /> Ll Public ❑ Other I f ❑ Delta <br /> •-ec--- <br /> ' -----�4pprox. depfti"l]-Eastern — Surface Seal Installed by <br /> ❑ <br /> Irrigation' State Work Done <br /> Repair Work Done Q Type of Pump ���� H.P. '� <br /> r '' Sealing Material Itop 501 <br /> I W411 Destruction ❑ Well Diameter ; .- <br /> Depth t^ Filler Material-(Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION .REPAJR/ADDITION 1 DESTRUCTION Q (Nosepticwinsystem00 feet.)itted of public sewer is <br /> Installation will serve: Residence Y Commerc+al =f Other <br /> Number of livingunits: Number-&f bedrooms Water table depth <br /> t 1 lr � - <br /> character of soil to a depth of 3 feet: <br /> - i I i} .Capacity No. Compartments <br /> SEPTIC TANK ❑ 'Type/Mfg.` , Method of Disposal <br /> PKG. TREATMENT PLT. El ''` i` it t <br /> r + Foundation Property Line <br /> i Distance to nearest: Well } � <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lined ice: Property Line - <br /> Foundation P rty <br /> i FILTER BED Q Distance to-nearest: i�, <br /> Well <br /> l tf e <br /> ❑ Depth Size Number <br /> SEEPAGE PITS Property Line <br /> f <br /> SUMPS L03Distance to nearas Well Foundation <br /> DISPOSAL PONDS ❑ <br /> l 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 /> 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."Contractors 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 California." <br /> The applicant u call or all MU re inspections. Complete drawing on rave�r� Cside,.�i <br /> Title:� '/ / Date: <br /> Signed <br /> FOR DEPARTMENT USE ONLY <br /> Date g Area <br /> Application Accepted by <br /> Final Inspection by Date <br /> Pit or Grout Inspection by Date , <br /> Additional Comments: <br /> [D Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca SM-7104 ❑ Tracy 83x6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i� <br /> FEE CK RECEIVED BY DATE PERMIT NO. <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> + EH 13-244REV.1/e 5) T <br /> EH W28 <br />