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s APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> I # Telephone (209) 466-6781 I <br /> 'PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i <br /> (Complete in Triplicate) <br /> Local Health District for a permit to construct and/or install the work herein described. This application is <br /> Application is hereby made to the San Joaquin <br /> I <br /> 9 for sewage or No. 18&2 for welllpump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No. 54t <br /> Local Health District. ''I. j <br /> 3 Cit ��ot Size PM <br /> Job Address Y <br /> Phone } <br /> Address <br /> Owner's Name <br /> 1 � � a1aa License No. Phone <br /> ant ac or <br /> dress <br /> WNEW WELL 71 WELL REPLA MENT 1-1RUCTION El <br /> TYPE OF ELL/PUMP: <br /> PUMP INSTALLATIO <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> N <br /> SEWER LINES DISPOSAL.FLD.' PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK --�»-_� <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ 1 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ! <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing �_ Specifications <br />'I mastic/Private ❑ Gravel Pack ❑ Tracy Type of Grout <br /> ❑ Other ] Cl Delta Depth of Grout Seal <br /> Public #! rface Seal installed by 4 <br /> I I Irrigation ,_Approxi,De h 1. tern t <br /> t r """ ^ 'State Work"i3one y <br />` Repair Work Done ❑ Type of Pump _ H�P:` <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 a <br /> Depth Ef Filler Material (Below 50') _. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t 1 REPAIR/ADDITION l i DESTRUCTION l 1 atvailabIC-w hin 200 feesebtir system tt�ed if public sewer <br /> is 6 <br />{ Installation will serve: Residence Commercial f Other <br /> Number of living units: Number of bedrooms <br /> Waterttable depth <br /> Character of soil to a depth of 3 ft ' I 1'" No.-Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ "Pro ert Line <br /> Distance to nearest: Well Foundation P Y <br /> t <br /> I Total length/size <br /> LEACHING LINE L1 No. & Length of lines <br /> k Io Property Line <br /> ` FILTER BED [_1 Distance to nearest: Well I <br /> �- I 1 Depth I Size Number <br /> j e <br /> SEEPAGE PITS iWell Foundation Property YLin <br /> SUMPS <br /> Distance to nearest <br /> DISPOSAL PONDS­LJ `"—' - M r <br /> 1 hereby certify that I have prepared this application and that the work wi11 be done in accordance with San Joaquin county ordinances, state laws, an <br /> rules and regulations of the San Joaquin Local Health Di§trict. <br /> fy that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I certi <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 followingI certify that in the performance of the work for which this ermit is issued, I shall employ persons subject to workman's compansa <br /> . pe p . <br /> tion laws of California." <br /> The applicant Gall for al r 're inspectipns. Compete drawing on rev se sid <br /> m etLl f <br /> Title: Date: 7 <br /> Signed <br /> / OR DEPARTMENT USE ONLY t� �2 / <br /> Uf Date / _ Area <br /> l Application Accepted by <br /> ��-- <br /> Date � I c j <br /> Pit or Grout inspection by Date Final Inspection by <br /> 1 <br /> Additional Comments: <br /> ❑ Stk 466-5781 . ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant Return,all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> F FCK RECEIVED BY DATE PERMIT'NO. <br /> EE <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> �.EH 13-24(REV.5 i H 5) <br /> EH 14-26 <br />