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E APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA n v <br /> Telephone (209) 466-6781 lJa" <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) application <br /> 11 the work <br /> Application is hereby made to the San Joaquin OLocal Health rdinance No.District49 for sewage or permit <br /> No 1862 forcwell and/or <br /> pump and he Rules and rReg�ations of the Sed.This Joaquin <br /> made in compliance with San Joaquin Co ty <br /> Local Health District. _. � r` <br /> , Lot Size PM <br /> i /r�3 C) .� pity <br /> Jab Address/ <br /> PC-2411 Phone <br /> Address <br />� Owner's Name r' <br /> t {� Phone <br /> fl / Address License N <br /> Contractor DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ <br /> SYSTEM REPAIR OTHER ElI PUMP INSTALLATION ElSYSTEM <br /> FLO. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK 1 <br /> i SEWER LINES �— PITS/SUMPS <br /> �- <br /> FOUNDATION AGRICULTURE WELL. OTHER WELL { <br /> INTENDED USE <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing y� <br /> ❑ industrial Ll Open Bottom _ ❑_1Glariteca----r — —- Dia• of Wek1 Excavation- Specifications a <br /> D <br /> k omestic/Private ❑ Gravel Pack ❑ Traci{ Type of Casing <br /> v Depth of Grout Seal Type of Grout <br /> ❑ Other I ❑ Delta <br /> ❑ Public Surfpce Seal Installed by <br /> ❑ Irrigation <br /> --Approx. `Dep EI-Eastern- Y ' <br /> /�,�� H P: State Work Done <br /> Repair Work Done Z Type of Pump,L' ;— <br /> Sealing Material (top 501 <br /> Well Destruction ❑ Well Diameter Fillet Material (Below 501 rn <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION C3aNailablelwthine200 feetftted if public sewer is l <br /> Installation will serve: Residence Commercial_— .Other — <br /> Number of living units: Number of bedrooms --r- <br /> Water table depth <br /> Character of soil to a depth of 3 feet: ' �.`° No. Compartments <br /> i \SEPTIC TANK ❑ Type/Mfg <br /> A Method of Disposal <br /> PKG. TREATMENT PLT. ❑ pro a Line <br /> Distance Jinearest: Well ' Foundation p <br /> 1 <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length}of lines property Line <br /> FILTER BED [I Distance toy nearest: Well Foundation <br /> I <br /> ' ',. Size Number <br /> SEEPAGE PITS ❑ Depth Property Line <br /> SUMPS ❑ Distance to nearest: Well Foundation <br /> r DISPOSAL PONDS ❑ k. .T <br /> f and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that l have prepared this application <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 /> ring or su <br /> employ any person in such manner as to become mance of to <br /> work for which#his <br /> workmancompensation <br /> is issued,of ifoah II employ peorsons'subj act to workman's b-contractIa mpensa- <br /> certifies the following: "I certify that in the.pe r.. Y <br /> tion laws of <br /> The applic mus call f 11 required ins ctions. Complete drawing on reverse side. <br /> �� Title: �� Date: {J <br /> Signed <br /> FOR EPARTMEN7 USE ONLY <br /> Application Accepted by Date <br /> i <br /> Pit or'Grout Inspection by Date <br /> Final Inspection by Date <br /> i Additional Comments: <br /> l ❑ 5tk 466 6781 ❑ Lodi 369-3621 D Manteca 823.7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Servic96-1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO AMO�UN`T DUE CASH f 'Yv l� <br /> / <br /> � <br /> + EH 13-24lAEv.,ie5r J i~ 00 <br /> EH 1426 <br />