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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone 1209) 466-6781 <br /> i. PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> r in <br /> all the work herein <br /> cation is <br /> madeinApplication <br /> ncomplitance withdSano the San Joaquin Local Health District for a Joags n County Ordinance No. 549 for sewage or permit <br /> No. 1862 forcwell/dpuomp and the Rules and Regulations of he Sank)aquin <br /> Local Health District. <br /> J Q[f City``!' Lot Size PM <br /> Job Address r� <br /> r, Owner's Name--f-4AN Address _ <br /> cs Phone <br /> fddress License No.� Phone_ T <br /> Contractor <br /> TYPE OF WELL/PUMP: .:: NEW WELL ❑ z WELL REPLACEMENT ❑ DESTRUCTION El <br /> { ,.,.J PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> E DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> _ t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> M ❑:Industrial # ❑ Open Bottom, ❑ Manteca Dia. of Well Excavation Specifications <br /> ❑,'Domestic/Private r LI Gravel Pack J. ❑ Tracy Type of Casing <br /> M*Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout - <br /> t ;I'i tlrrigataon t ' --Approx. Depth T I I Eastern <br /> Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction El Well Diameter Sealing Material )top 501 <br /> Depth- Filler Material :Below 501 <br /> P I TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l i DESTRUCTION I } INo septic system permitted if public seer is <br /> I available within 200 feet.) <br /> �� <br /> Installation will serve: Residence'! CommercialOther h <br /> Number of living units: --,/— Number of bedrooms tLJ` <br /> Character of soil to a depth of 3 feet t3£� Water table depth d <br /> SEPTIC TANK""" -E] Type/Mfg4!5� e,0 Capacity No. Compartments <br /> i <br /> PKG. TREATMENT;PLT: 11 _. P Method of Dispo�al <br /> Distance to nearest: Well Foundation __ Property Line _ LD <br /> r <br /> LEACHING LINA E PR'--No. & Length of lines [7 TStal length/size <br /> FILTER BED'E ❑ Distance to nearest: Well/00 Foundation/Q y"* Property Line _— <br /> # � <br /> SEEPAGE PITS I'r--Depth gnq Size - Number <br /> t SUMPS R. 0 '[Astarice to nearest: Well /S O -. Foundation d 170' Property Line. ZQ 14 — <br /> DISPOSAL PONDS" ❑ <br /> I hereby certify *fiat) have prepared this application and that the work-will be done in accordance with San.Joaquin'caunty ordinances, state laws, and <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 /> 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 Cal- -a." ) <br /> � k <br /> The applicant mus call for (_require nspections. Complete drawing on reverse side. <br /> i t <br /> i Signed Title: Date: <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> s <br /> ' t Date Area <br /> Application Accepted by <br /> i <br /> Pit or Grout Inspection �: Date ' Final Inspection by Date <br /> b <br /> Additional Comments: ' <br /> ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823 7104,a,� ❑;Tracy 835-6365 <br /> -,,. —Applicant�Return_all.copies_to:•Environmental_Health-P-ermit[Servicea 1601 E. Hazelton Ave—P.O._Box.2009,-S k.. <br /> I <br /> FEE AMOUNT DUE AMOUNT REMITTED / 'CASH RECEIVED By`, DATE PERMIT NO. <br /> INFO 1h, YY11I: QI (Q)(O7 <br /> +.EH 13-24(REV.1/115) O, D� • <br /> EH 14-26 <br />