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..� r <br /> APPLICATION FOR PERMIT ���, <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 �ll� <br /> PERMIT EXPIRES 1 YEAR"FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> work <br /> This <br /> cation <br /> is <br /> all the <br /> Application hereby made to the San Joaquin quin Local Health District for a permit to construct62 for well/pumpand the Rules and'Regukations of he Sanl Joaquin II <br /> made in compliance with San Joaquin Conty Ordinance No.549 for sewage or No. <br /> Local Health District. <br /> `J �1 City of Size PM { <br /> Job Address rTo� <br /> Owner's Name <br /> I Address <br /> License No. ^�---Phone <br /> Contractor Address I <br /> WELL REPL2ACEMENT,❑ ,. -_ DE TRUCTION LJ_ <br /> TYPE OF WELL/PU P: NEW WELL ❑ SYSTEM REPAIR Q OTHER ❑ <br /> PUMP INSTALLATION ❑ PROP. LINE <br /> ES DISP L FLD. ' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINHER WELL PITSlSUMPS <br /> FOUNDATION GRICULTURE WELL qq r <br /> I INTENDED USE TYPE OF WELL PROBLEM A CONSTRU N SPECIFICATIONS f Dia. of Well Casing <br /> EJ Industrial ❑ a. ell Excavation Industrial Open Bottom <br /> Manteca i Specifications <br /> r g <br /> Ll Domestic/Private ❑ Gravel Pack ❑ Tracy ype 65tH w Type of Grout <br /> ❑ Other Cl ' <br /> Delta Depth of Gr Seal <br /> M i Public <br /> t f �. 1 <br /> _Approx. Depth astern Surface Seal Insta by <br /> I 1 Irrigation — r ate Work Done= <br /> Repair Work Done ❑ Type of Pump H.P. I <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Filler Material (Below 56'1 perm (�1 <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t 1 REPAIR/ADDITION LI DESTRUCTlO available within <br /> 200(No septic sYste feet��jed if pudic sewer is <br /> Installation will serve: Residence " " Commercial_ Other S l+t <br /> Number of living units: Number of bedrooms <br /> r Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> � <br /> SEPTIC TANK ❑ Type/Mfg Capacity 1 Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well Foundation P Y <br /> f -I <br /> 11 LEACHING LINE 171No. & Length of lines Total length/size <br /> Property Line <br /> FILTER BED ❑ Distance to nearest: Well Foundation P Y <br /> Size Number <br /> SEEPAGE PITS l I Depth r I Property Line <br /> SUMPS Ll Distance to nearest: Well Foundation <br /> 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 issued, 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 /> t 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 t tail for all requir i spections. Complete drawing on reverse side. <br /> Title: 2nme�� Date: --� <br /> Signed X <br /> � ARTMENT USE ONLY <br /> I pate Area <br /> Application Accepted by <br /> Dat Final Inspection by Date <br /> Pit or Grout Inspection by �/- <br /> F Additional Comments; °L i <br /> i LJStk 466-6781 ❑ Lodi 369-3621 El Manteca 823-7104 ❑ Tracy 635 6385 <br /> Applicant- Return all copies to:,Environmental Health Permit/Se ices 1601 E. Hazelton Ave., P.O. Box 2009, CA 35201 <br /> %H <br /> CK RECEIVED BY DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> s� <br /> + EH 13-24(REV.1/n sI <br /> EH 14.26 / �, <br />