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Y- APPLICATION FOR PERMIT <br /> -� SAN JOAO,UIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE.,_STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> (Complete in,Triplicate) <br /> n describ . This applcation is <br /> � . <br /> Application is hereby made to the San Joranui Ordinalnce <br /> No.D549 for sewage or lt to cd/or install the work r <br /> No. 1862 forwelllpump and the Rules and R gulations of he San'Joaquin <br /> made in compliance with San Joaquin Co ty <br /> Local Health District. �" <br /> { C� *City 1_ Size PM <br /> Job Address u <br /> Phone <br /> Address <br /> - � Owner's Name _ g 1 <br /> '7 6 <br /> A 3�gf f_ License No: .g Y Phone <br /> Contractor aJ ► Address <br /> WELL REPLACEMENT fl DESTRUCTION.._❑• <br /> TYPE OF WELL/PUMP:: is .�SYSTEM REPAIR E] OTHER'Dw <br /> P,LIMP-INSTALLATION--❑ �-�"� 1 DISPOSAUFLD.___— PR <br /> I DISTANCE TO NEAREST: SEPTIC TANK SEWE-- i i ---� PITS/SUMPS <br /> FOUNDATION <br /> AGRICULTURE WELL OTHER WE " <br /> ' <br />'k CIFICATIONS <br /> INTENDED USE--•---!«'TYPE-OF WELL-^'} PROBLEM•A'REq CONSTRUCT Dia. of Well Casing <br /> Cl Open Bottum j ❑ Mant Well Excavation <br /> Cl Industrial } '' Type of.Casing Specifications <br /> ❑ Tra Type of Grout <br /> ❑ Public <br /> Domestic/Private ❑ Gravel Pack Delta ' Depth of Grout Seal <br /> s ❑ Other e <br /> I <br /> Public Surface Seal Installed by <br /> © Irrigation ox. Depth ❑ Eastern` t State Work Done <br /> Repair Work Done Type of'Pump = H.P. <br /> t <br /> ` "^ """"""Sealing Material (top 50') <br /> Well DD ton ❑ <br /> Well Dia deter <br /> Depth -� � I Filler Material (Below 50') <br /> available within 200 feet.) <br /> TYPE OF SEPTIC WORK: NEINava <br /> STALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (Noava septic system permitted if public sewer is <br /> Other <br /> installation <br /> i Installation will serve: Residence Commercial <br /> f Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: t Capacity�� No. Compartments F <br /> SEPTIC TANK I ❑ Type/Mfg 1 Method of,Disposal <br /> PKG.' TREATMENT PLT. I-)., Property Line ``� <br /> Distance to nearest: Well <br /> Foundation t F <br /> Total length/sizer <br /> LEACHING LINE ❑ No. & Length of lines Property Line ' <br /> Q. Distance to nearest: Well Foundation <br /> FILTER BED ' <br /> i. <br /> 4 - r <br /> Size Number <br /> SEEPAGE PITS CI Depth Foundation Property Line <br /> ❑ <br /> SUMPS € <br /> Distance to nearest: Well - r;$ <br /> DISPOSAL PONDS ❑ <br /> r will be done in accordance with San Joaquin county vrdinarices, state laws, and <br /> I hereby certify that I have prepared this application and that the work <br /> rules and regulations of the San Joaquin Local Health District. work for this permit is <br /> l not <br /> Home owner or licensed h ent's signature <br /> gas <br /> tobecomesub sthe ubject wlng:orkman s coympensat4hat in ion laws of California." Contractor's which <br /> rhiring or sub-cont actidng signaturelaturre <br /> employ any person arsons subject to workman's compensa <br /> I certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ p i <br /> tion laws of California." Complete drawing verse side. <br /> on reD <br /> The applicant call for all required inspections. <br /> ate: - <br /> Title: <br /> Signed X LL _ f <br /> 1 f '' , u , FORsDEPARTM�ENT USE ONLY <br /> Date Area <br /> ' Application Accepted by <br /> Date a". <br /> - pale Final inspect by <br /> "" Ptii or Grout Inspection bye <br /> Additional Comments: Trac 835- W) <br /> $ 1-1Stk 466-6781 ❑ Lodi 369-3621 ❑ Mant ca 823- 1D4 Y <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> w <br /> sCK RECEIVED BY DATE PERMIT N <br /> FEE AMOUNT DUE AMOUNT REMITTED ` <br /> t INFO <br /> ' •+ EH 13-241fiEV.1/H51 / <br /> .lam (r•�"'++r <br /> EH 14-26 <br />