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APPLICATION FOR PERMIT <br /> f. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 j <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> } i <br /> (Complete in Triplicate) <br /> scribed.This <br /> all the work <br /> Appplcation is <br /> ic omphance withdSanoJoaquin the nCou Qty Ordinance No.549 for sewage or uin Local Health District for a permit <br /> 1862 for we l/dpumlp atnd the Runes and hereinR Regulations of the Sant Joaquin <br /> ma <br /> Local Health District. <br /> Job Address <br /> City Lot Size PM <br /> i� <br /> d � Phone <br /> Owner's Name Address <br /> I <br /> Contractor <br /> r1 Address License No. Phone <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D <br /> PUMP INSTALLATION EJ SYSTEM REPAIR L1OTHER 11 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL pITS1SUMPS �1 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing V <br /> ❑ industrial ❑ Open Bottom El Manteca Dia- of Well Excavation <br /> Type of Casin Specifications <br /> L3 Domestic/Private C7 Gravel Pack ❑ Tracy yp g Type of Grout <br /> F1 Public F1 Other Cl Delta Depth of'Grout Seal <br /> E I I Irrigation W`' , --Apprcm.-Depth l 1 Eastern Surface-Seal in54��alled by <br /> H.P. -- ---- - yState Work Done — <br /> Repair Work Done ❑ - Type of Pump ,a.,. <br /> Well Destruction ❑ Well Diameter '" Sealing.Material (top- <br /> Depth <br /> top Depth "M1 Filler Material {Below 501 <br /> I TYPE OF SEPTIC WORK: NEW-INSTALLATION [.'I REPAIR/ADDITION I 1 DESTRUCTION {�ailabPe0selwit in 200 feet.)system if public sewer is <br /> Installation will serve: Residence Commercial Y Other <br /> Number of living units: Number of bedrooms <br /> Y.; 11 Water,table depth . <br /> k Character of soil to a depth of 3 feet: <br /> f Capacity No. Compartments <br /> SEPTIC TANK�"""'^"c 0 - Type/Mfg <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> l Distance to nearest: Well Foundation Property Line <br /> I. <br /> i LEACHING LINE 171 No, & Length of Nnes <br /> Total length/size 'v <br /> FILTER BED 13 Distance to nearest: Well Foundation Property Line <br /> ;I <br /> 1 <br /> SEEPAGE PITS C1 Depth Size Number <br /> SUMPS .- Ll .Distance to nearest: • We1L Foundation Property Line <br /> I DISPOSAL PONDS ❑ <br /> 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 traced, I 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,l shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant st call far all r quirad inspections. Complete drawing on reverse side. ? <br /> Signed X Title: <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Area <br /> Application Accepted by / <br /> Pit or Grout Inspection by Date Final Inspection by moo, c-��(��(�, Date <br /> Additional Comments: <br /> ✓L <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Ewironm ntal ealth Permit/ 0rvic)es 1601 E. Hazelton P.0 Box 2009 tk. CA 5201 <br /> i f2T <br /> RECEIVED BY DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED C <br /> ' ♦ EH 13-241 REV.1rn51 <br /> EH 14.26 <br /> i <br />