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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> ]PERMIT EXPIRES 1,YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> uin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> Application is hereby made to the San Joaq <br /> No.549 for sewage or No. 1862 far well/pump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance <br /> Local Health District. <br /> s City moi. Lot Size Il X PM <br /> Job Address r <br /> Aa n I Address D_+ P— JQ Phone <br /> Owner's Name. � <br /> is x �� License No. Phone " <br /> Contractor Address <br /> TYPE OF WELL/PUMP:. NEW WELL ❑ WELL REPLACEMENT 17 DESTRUCTION LJ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C1 <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial '❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing <br /> El Domestic I Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> Specifications <br /> fl Other F1 Delta Depth of Grout Seal Type of Grout <br /> Ll Public - _• � <br /> 1 Irrigation _�..Approx.,Dapth_ I1 E stern Surface Seal Installed by <br /> ~^-�^ WState Work Done <br /> Repair Work Done ❑ Type of Pump H.P. <br /> i <br /> Well Destruction El Well Diameter Sealing Material (top 501 <br /> ' Depth Filler Material (Below 501 <br /> f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l REPAIRIADDITION l I t]ESTRUCT"ION No septic system permitted if public sewer is <br /> r available within 200 feet.) <br /> i <br /> Installation will serve: Residence, Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK LI Type/Mfg <br /> Capacity No. Compartments <br /> ! <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> t Distance to nearest: Well r­Fouridkion Property Line <br /> LEACHING LINE ❑ No. & Length"of lines _ ry . __I '_Total.length/size G <br /> ., ..,.r.w.-s:�......... ... - - <br /> FILTER'BED ❑ Distance to nearest: Well Foundation Property tine I • <br /> h SEEPAGE PITS I Depth Size Number <br />` SUMPS L-1 Distance to nearest: Well Foundation F .Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 agents 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 parmit'is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applican roust all for all required in_spections_Complete drawing on r/eversee side.; <br /> Signed X � Title: '`" �% _ s -Date: <br /> FOR DEPARTMENT USE ONLY 7 <br /> Date � Area <br /> Application Accepted by <br /> ` <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ddd ElStk 466-6781 ElLodi 369-3621 ❑ Manteca 823-7104 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 CK RECEIVED BY DATE PERMIT"NO. <br /> INFO ry�1, f <br /> + EH13-24(REV.1 5) 3s � 2+ <br /> EH 14-26 J <br />