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APPLICATION FOR PLAMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ; <br /> 1601 E. HAZE,-TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 - <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Appicaon is t and/or install the work <br /> .-This application is <br /> madle inti <br /> omplilance writhdSan Joaqu nae to the San CouJoanty Ord nauin Localncfe No. 549 for sewage or ealth District for a permit <br /> 1862 for cweil pump and the Rules and IR Regulations of the San Joaquin <br /> Local Health District. <br /> / c <br /> ,� _ City Lot Size PM <br /> Job Address <br /> i�� Address Phone <br /> Owner's Name C _ <br /> Contractor Address / �/�/�. C'_. License No. r Phone <br /> � � f � ��- <br /> a/- <br /> TYPE OF WELL/PUMP: NEW WELL; WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION >� SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK �f SEWER LINES DISPOSAL <br /> FLD. ��° PROP. LINE <br /> gym <br /> r OUNDATION - AGRICULTURE WELL ^ AX vvEL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS /f <br /> El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ 0 Dia. of Well Casing <br /> Type of Casing Specifications <br /> Ct'i <br /> Domestic/Private Gravel Pack ❑ Tracy yp T e of Grout <br /> (1 Public _❑ Other ❑ Delta Depth of Grout Seal. f Type <br /> f I I Irrigation � Approx. Dept tern f Sydace Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. 1 / State Work Done_ <br /> Well Destruction ❑ Wel! Diameter Sealing Material {top 501 " <br /> Depth Filler Material IBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1:1 REPAIR/ADDITION I i DESTRUCTION I I lNo septic system permitted if public sewer is <br /> L available within 200 feet.) <br /> Installation will serve: Residence{ Commercial— Other F <br /> Number of living units: - Number of bedrooms <br /> Character of soil to a deptof 3 feet: Water table depth <br /> h <br /> SEPTIC TANK ❑ Type/Mfg a Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ 'r Method of Disposal ' <br /> Distance to nearest: Well % Foundation Property Line <br /> .N. V <br /> r� � --� <br /> LEACHING LINE. ❑ No. & Length of lines Total lengthlsize Q <br />` FILTER BED ❑ Distance to nearest: '.. Well Foundation Property Line. <br /> SEEPAGE PITS i I Depth Size Number Q <br /> SUMPS 'Ll' Distance to nearest: Well Foundation Property Line [[ <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that t 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, 1 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, !shall employ persons subject to workman's compensa <br /> tion laws of California." <br /> The applicant -r II requ" ctions. Complete drawing on reverse side. <br /> f Signed X — Title: f� s -+ -� ' Date: <br /> .` <br /> FOR DEPARTMENT USE ONLY <br /> �J ` <br /> Application Accepted by L/ Date (� Area ) <br /> Pit or Grout Inspection by Date -Z Final Inspection by Date 7 '�� <br /> Additional Comments: <br /> r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> 1 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2005, Stk., CA 95201 <br /> I FF E ~ -CK RECEIVEQ t3Y DATE PERMIT'NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> F <br /> ? ♦.EH1324tREV.1/n51 <br /> I EH 14-2a <br /> C-10-3�Da <br />