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y-- <br /> APPLICATION E MIT <br /> ATi N FOR.. RP T 4 <br /> SAN JOAQUIN LOCAL1HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6761 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> is <br /> Application is hereby made to the SanCoun u(O dina'nce Na.HealthD549 for istrict Topermitr a <br /> cation <br /> wage or No. 1862 for well and/or herein <br /> pump and the Rul s and Regulations of he Sanl Joaquin <br /> made in compliance with San��aq �1L �? �N <br /> Local Health District. <br /> City Lot Size PM <br /> Job Address -v <br /> Phone/ <br /> Owner's Name � Address <br /> License No. Phone <br /> Contractor's Name 11 DESTRUCTION C)TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ � <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ q <br /> SEWER LINES DISPOSAL FLD. PROP. LINE I <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS � 1 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL l <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> Industrial ❑ Open Bottom © Manteca of Well Excavation <br /> Dia. Specifications <br /> ❑ Tracy Type of Casing <br /> Type of Grout <br /> [1Public ❑ Other ❑ Delta <br /> „�,pprox. Depth ❑ Fem Surface Seal Installed by <br /> ❑ Irrigation State Work Donet,. <br /> Repair Work Done ❑ Type of Pump Seating Material {top 50'I <br /> O <br />�> Well Destruction C1 Well Diameter �— <br /> SeaG <br /> Depth Filler Material{Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION DESTRUCTION ❑ (Nailable1witsystem <br /> ne200 feet.)ed rf public sewer is <br /> . N <br /> Installation wH1 serve: Residence 00!Commercial Other <br /> Number of living units: Number of ooms Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK . ❑ Type/Mfg Capacity No. Compartments <br /> _ Method of Disposal <br /> PKG. TREATMENT PLT.❑ Property Line <br /> - Distance to nearest: Well � Foundation�— <br /> Total len gthlsize <br /> LEACHING LINE )9:L No. &Length of lines _ - <br /> Q7 Foundation��1 r�— Property Line <br /> FILTER BED 11Distance to nearest: WPI�— <br /> Size lyumber <br /> SEEPAGE PITS Depth. r /y Property Line <br /> SUMPS <br /> ❑ Distance to nearest: Well l0 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. that in the performance of the work for which this permit is issued, 1 shall riot <br /> Home owner or licensed agent's signature certifies the following: "f certify <br /> employ any person in such manner as to become subject to workman's cosignature <br /> mpensation laws of California."Contvacthiring <br /> subject t workmant's9ompensa <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons <br /> tion laws of Calif <br /> The applice ust call for requir spectionS. Complete drawing on reverse side. <br /> P ,� Date: <br /> Sign d <br /> FOR DEPARTMENT USE ONLY <br /> Date t Area <br /> Application Accepted by r^ <br /> Date 1� 3 Final Inspection bBate <br /> Pit or"Grout Inspections � C�QF <br /> t Additional Comments: �� <br /> ❑ Stk 466-Ml ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> IJ2 �•r V00 <br /> �y mmDATE P£RMIV'NO. <br /> R RECEIVED <br /> C BY <br /> FEE AMOUNT DUE AMOUNT REMITTED r <br /> INFO <br /> F +E14 13-24(REV.10193) <br /> EH 1426 <br />