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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 f <br /> PERMIT EXPIRES 'I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) applicationn described.TNs is <br /> all the work <br /> Application is hereby made n J h u n County Ordinance Health District <br /> No,549 for sewage or <br /> mit to <br /> 1862 for welllconstruct dpump atnd the Rules and(Regulations of he San Joaquin <br /> made In compliance with San �q <br /> Local Health District. �3 <br /> -7 D S-, Ge/ City r7 ' lot Size i'M <br /> Job Address <br /> + Phone <br /> Address <br /> Owner's Name <br /> Phone <br /> r <br /> Contractor's Name License No.WELL REPLACEMENT ❑ DESTRUCTION <br /> OF WELLIPUMP: NEW WELL ❑ OTHER 11TYPE <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ , <br /> — DISPOSAL FLD. PROP. LINE <br /> SEWER LINES — 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL ' t OTHER WELL PITS/Sl <br /> FOUNDATION �-- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Wel! Casing if <br /> xc <br /> ❑ Industrial C] Open Bottom El Manteca of Well Eavation Manteca Specifications <br /> Type of Casing <br /> � ❑ Domestic/Private D Gravel Pack Q Tracy Depth of Grout Sea! Type of Grout <br /> ❑ Public <br /> D Other Cl Delta <br /> tt .• ��pprox. Depth ❑ Eastern --� Surface Seal Installed by— � <br /> h w ❑ Irrigation St to Wo;k Done <br /> Repair Work Done ❑ TYpe of Pump,�1+ Seal Sealing Material )top.50') 111 <br /> Well Destruction Well Diameter <br /> Filler Material (Below 50'1 <br /> epth <br /> available within 200 feet.)` , <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION LlREPAIR/ADDITION m❑ DESTRUCTION ❑ (No septic systepermitted if public sewer is <br /> -Installation-will serve: -Residence- =°Commerc'sal Other– <br /> Number of living units: Number'of bedrooms Water table depth <br /> -- Character of soil to a depth of 3 feet: No. Compartments <br /> ❑ Type Mfg i Capacity <br /> SEPTIC TANK _ Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Line <br /> Distance to nearest: Well Foundation Property <br /> r <br /> iTotal length!size <br /> LEACHING LINE ❑ No.�& Length of lines <br /> I FILTER BED El Distance to nearest: Well <br /> Foundation�— Property Line <br /> Size Number <br /> SEEPAGE PITS [3 Depth <br /> SUMPS Pro line <br /> ❑ Distance to nearest: Well Foundation Property <br /> - ' <br /> DISPOSAL PONDS D <br /> 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 /> l not <br /> ritify that in the <br /> --'� rules and regulations of the San Joaquin Local Health District. work for <br /> Home owner or licensed agent's signature certifies the following: "I <br /> become subject to workman s compensation iawsoof California. Contractor's'hiring or this sub-contracting signaturermit is issued, I <br /> employI employ any person in such manner <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 compen - <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> ....10 Title: Data: <br /> �� <br /> �. ...� <br /> FOR DEPARTMENT USE ONLY <br /> � <br /> Date <br /> ✓ v– Area <br /> � Application Accepted by Date <br /> -� Date Final Inspection by <br /> Pit or Grout Inspection by <br /> Adcoonal Comments: ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> 466-6781 ❑ Lodi 369-3621 Stk., CA 95201 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, <br /> CK RECEIVED BY DATE PERMIY'NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED <nzwlv <br /> INFO �b n f��/n 9-z4_19-4 9 105 <br /> / <br /> + EH 13.241REV.10183) <br /> EH 1426 <br />