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9 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> quin Local Health District for a permit to construct and/or install the work herein described. This applicatio <br /> Application is helehy made to the San Joan is <br /> or No. 1862 far well/pump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage <br /> Local Health District. <br /> I <br /> � � �'1 City Lot Size PM <br /> Job Address <br /> Owner's Name �� <br /> �- Address Phone <br /> �� � � AddressL � g6� <br /> Contract- J License No. ` <br /> TYPE OF WELL/PUMP: NEW WELL D <br /> WELL REPLACEMENT ❑ DESTRUCTION.C1 <br /> PUMP INSTALLATION IY SYSTEM REPAIR ❑ OTHER D-A� s <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD- PROP- LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Ind strial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> - Type of Casing Specifications <br /> i'GomestccIPrivate Cl Gravel Pack ❑ Tracy yp Type of Grout <br /> I'I Public, (7 Other 1-1DeltaDepth of Grout Seal <br /> I I Irrigation --Approx. Depth l I Eastorn Surface Seal Installed by <br /> i 12 <br /> * i H p � ) State Work Done <br /> 4yrFtepair Work Done — Type of Pump �:+ } <br /> Well Destruction ❑ Well Diameter Sealing Material Stop 501 +1/ <br /> * Depth—" Filler Material (Below 50'1 - - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I, VEP_AIR/ADDITION 1 l DESTRUCTION I I iNo sealvailaptic system <br /> m retitled it public sewer is <br /> i i l <br /> 4t <br /> Installation will serve: Residence, Commercial Other <br /> Number of living units: Number of bedrooms <br /> T� Character of soil to a depth of 3 feet: +} Water table depth <br /> f SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT- ❑ ;, r. <br /> r <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. R Length of lines Total length/size <br /> I • j <br /> FILTER BED ❑ Distance?o nearest: Well Foundation Property Line <br /> `` 'r Size Number <br /> SEEPAGE PITS I I Depth <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 1 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 Di§trict. <br /> Home owner or licensed agent's signature certifies the following: "1 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 /> 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 must al. for ail r#q red inspections. Complete drawing on reverse side. <br /> & <br /> _ <br /> Title; An4 Date: <br /> Signed X zT CJ - <br /> R DEPARTMENT USE ONLY <br /> .2l6 <br /> Application Accepted by <br /> Date Area <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date <br /> > Additional Comments: <br /> El Stk 466-6781 ❑ Lodi 369 3E21 ❑ Manteca 823-7104 El 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 /> FEECK .` RECEIVED BY DATE PERMITNO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> +.EH 13-241t1Ev.F/nsl ` 30 <br /> p C>yip Z. <br /> EH 14-26 <br />