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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA i <br /> Telephone (209) 466-6781 is <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) ation is <br /> t and/or in <br /> all the work <br /> madecntcompliance with Satn Joaqu nn County ordinaJoaquin Localnce No.549 for sewage or Health District for a permit <br /> 1862 for cwetl pump and the Rules and herein <br /> gulations of the San l Joaquin <br /> Local Health District. t1 4 <br /> O �.l q Q' City Lot Size L4 PM <br /> Job Addres r <br /> ' (09-2s <br /> Address Phone <br /> Owner's <br /> 'r ��� License No Phone <br /> Contract Address <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1°i <br /> f PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> DISPOSAL FLD. PROP. LINE # <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ` i <br /> Y f - FOUNDATION AGRICULTURE WELL. - OTHER WELL PITS/SUMPS x ; <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing a <br /> F1 Industrial 11 Open Bottom ❑ Manteca Dia. of Well Excavation p _ <br /> Type of Casing Specifications ice` <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Grout--' <br /> M Public f❑ Other F] Delta Depth of Grout Seal - <br /> 1 Irrigation Approxi Depth l I Eastern <br /> Surface Seal Installed by - <br /> I H P State Work Done <br /> Repair Work Done . ❑ Type of Pump f <br /> Well Destruction ❑ Well Diameter Sealing Materia! (top 501 <br /> ty1 Depth Filler Material (Below 501 perm <br /> j TYPE OF-SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 1 1 DESTRUCTION I I al o septic s yem <br /> st 200 ieettled if public sewer is <br /> Installation.will serve: Resi ence Commercial Other <br /> Number of.-tieing units: Number of e room <br /> r Water table depth <br /> Character`of rsoil to a depth of 3 feet:f , <br /> r Capacity Compartment, <br /> SEPTIC TANK 1X_Type/Mf 9' r <br /> PKG. TREATMENT PLT. ❑ C f t Method of Dispysal <br /> !' <br /> - Distance'to nearest: Well Foundation_ ® Property Line_— .-- <br /> r -- o' Total length/size <br /> LEACHING LINE ;No. & Length of lines �� <br /> ;Q — Property Line <br /> FILTER BED ❑,,,Distance to nearest: Well Foundation <br /> If e <br /> JN. - - -" Number r <br /> t SEEPAGE PIIS• Depth `' Srze c. <br /> I SUMPS i� ❑ Distance to nearest: Well Foundation Property line <br /> r 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 taws, and <br /> rules and regulations of the San Joaquin Local HealtKDi?trict.r 4 r,, -:r—,k 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`persan in such manner as to become subject to workman's comperisation,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 permi't•isis� I shall employ persons subject to workman's compensa <br /> tion laws of-California." <br /> I <br /> ( The appliaAccepteby <br /> ire -nspections.JComplete_dr�in�g_an-reverseYsi� <br /> Signed X Title: " ...�Date: <br /> gE .. .-a. <br /> I FOR DEPARTMENT USE ONLY <br /> I _ CfrJ.� -C'.',\, I Date 1 l-- r`r _� Area �d75 <br /> { _ ��r ( r a <br /> out Inspection b Date <br /> \�I � Final Inspection b� Date <br /> Additional Comments: <br /> ElStk 486-6781 El 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 /> FEE AMOUNT DUE AMOUNT REMITTED r CK CASH RECEIVED YY DATE PERMIT NO. <br /> a.EH 13-241REV.1/H51 , �V _O <br /> EH U-2e <br />