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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781` a <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED k, , <br /> j.�r•:. (Complete in Triplicate) <br /> /or install the work herein describ . Ths <br /> cation is <br /> Application is hereby made to the San Joaquin OrdinalHealth nce No.District549 for sewage or(t to construct No. 1862 for well//pump and the Rules and R gulatioons of he San Joaquin <br /> made in compliance with San Joaquin County <br /> Local Health District. � Y <br /> C II. city 'Lot Size., PM <br /> � - <br /> Job Address <br /> /rl Phone 9.� <br /> Owner's Name Address <br /> �y <br /> / 1 1�t% License No. _i 7 r - Phone a <br /> J <br /> � <br /> Contractor's Name j <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Ll # <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ i + <br /> DISTANCE TO NEAREST: SEPTIC TANK / SEWER LINES DISPOSAL FLD. _ PROP. LINE i I <br /> FOUNDATION _ AGRICULTURE WELL; OTHER WELL PITS/SUMPS-- <br /> 4,5 <br /> INTENDED USE TYPE OF WELL t, PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial .1-1Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other f ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation WApprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. State Work Done 'Pag <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') ` <br /> I <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION'❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is j <br /> f _ available within 200 feet.) ; <br /> Installation will serve: 'Residence Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> f Character of soil to a depth of 3 feet: ^Water table depth <br /> j SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT: <br /> 71 Distance <br /> of Disposal <br /> Distance to nearest: Well Foundation, Property Line <br /> r. <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS `❑ <br /> l I hereby certify that I 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 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 California." <br /> The applicant must call for all required inspectio s. Complete drawing on reverse side. 9 <br /> Signed Title: _(yvt � '� Date: <br /> FOR DEPARTMENT USE ONLY <br /> r <br /> Y <br /> Application Accepted by Date Area p/ <br /> Pit or Grout Inspection by Date Final inspection by <br /> Additional Comments: <br /> ❑ Stk 4664781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 .0 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 CASH RECEIVED BY DATE PERMIT`N0. <br /> ` INFO <br /> +EH 1324(REV.101831 <br /> EH W28 <br />