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APPLICATION FOR PERMIT <br /> SAN JOAQUIN-LOCAL HEALTH DISTRICT <br /> 1661 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 /> aquin 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 Jo <br /> go or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for sewa <br /> Local Health District. rir <br /> City et Lot Size /�'" PM <br /> � <br /> Job Address <br /> Owner's Name <br /> Address Phone <br /> Address License No. 3� Phone_ <br /> kA <br /> Contractor <br /> TYPE OF WELL/PUMP: NEW WELL 1­1WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO <br /> NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/ <br /> SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - I <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> Type of Casing Specifications � E,z <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy 9 ; . <br /> ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> (1 Public _ <br /> I I I Irrigation _.Approx. Depth I 1 Eastern Surface Seal installed by <br /> Repair Work Done ❑ Type of Pump H,P. State Work Done <br /> Sealing Material Ito 50'1 <br /> i Well Destruction ❑ Well Diameter fd p <br /> r Depth r Filler Material IBelow 501 <br /> t TYPE OF SEPTIC WORK: NEW INSTALLATION lh' REPAIRIADDITION 1.1 DESTRUCTION tavailabPi cy200 f e <br /> stem <br /> permitted if public sewer is <br /> e <br /> Installation will`serve: Residence= Corn rnercial'�� Other <br /> Number of living units: Number of bedrooms _ a <br /> 4 Character of soil to a depth of 3 feet: <br /> y [ Water table depth <br /> { S ; k ❑ Type/Mfg Capacity— µ No. Compartments <br /> SEPTIC TANK <br /> f x Method of Disposal <br /> PKG. TREATMENT.PLT. ❑ a _ <br /> j - <br /> Distance to nearest: Well Foundation Property Line <br /> ��.-•yrs-. - - <br /> LEACHING LINE t .r ❑ No. & Length of.,lines `E Total length/size <br /> FILTER BED 1 1-1Distanceto nearest: Well f Foundation Property Line <br /> 'mow t <br /> t SEEPAGE PITS I I Depth Size Number <br /> } SUMPS t ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that She 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 /> i _ <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, 1 she not <br /> 1 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 /> 'ties the following' '" rtify that in the performance of the work fof which this permit is issued, I shall employ persons subject to workman's compensa <br /> tion la f Calif mi r <br /> The applica t t call <br /> for lI re' fired i c lets drawing P raver ff <br /> �' �V Dater <br /> Signa Title. <br /> 1 FOR DEPARTMENT USE ONLY I <br /> l Application Accepted by� .____ - — <br /> iDa[ <br /> I Pit or Grout Inspection by ate Final inspection by <br /> i Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 <br /> Applicant -..Return all copies toEnvironmental Health Permit/_Services J604 E.,Hazelton.Ave.,,P.O..Box 2009,_Stk.,.-CA.95201 .-- -•�—�- -� <br /> FEE AMOUNT DUE hAfu10UN7 REMITTED'— CA5H RECEIVED BY DATE PERMIT�NO. s <br /> INFO —Y- <br /> Air' + EH 13-24 rREV.t r n 51 <br /> EH 14-2d <br />