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1S`.:- . <br /> { <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate)` <br /> ior install the work <br /> cation is <br /> Application is hereby mads no,ha Joaquin Co pty Oirdinance No.549 for sewage or ocal Health District for a permit <br /> 1862 for wellldpump and the Rules and'R Regulations of tthe Sis ans Joaquin <br /> made in compliance with 4 <br /> Local Health District. <br /> 67 Ci Lot Size PM <br /> ,lob Address � �,' <br /> A q 3z s or+► Pho <br /> ress <br /> d <br /> Owner's Nam _ <br /> Contractor Address <br /> License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL LJ WELL REPLACEMENT D DESTRUCTION C1 <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION L1 <br /> �-- DISPOSAL FLD. PROP. LINE <br /> SEWER LINES (� <br /> DISTANCE TO NEAREST: SEPTIC TAINK AGRICULTURE WELL OTHER WELL— <br /> INTENDED <br /> FOUNDATION <br /> INTENDED USE TYPE OF WELL PROBLEM AREA- CONSTRUCTION SPEC Dia. of Well Casing <br /> Open Bottom d Manteca Dia xcavation <br /> ❑ Industrial Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tra <br /> Type of Casing <br /> Delta "Depth of Grout seal Type of Grout <br /> t n Public Ci Other - <br /> stern Surface Seal Installed by <br /> I I irrigation prox. Depth I 1 Ea <br /> ! � -Type of Pump H.P. <br /> State Work Done_ <br /> Repair Work D , <br /> ruction ❑ Well Diameter Sealing Material Stop 501 <br /> • Depth <br /> I Filler Material IBelow 50'1 <br /> TYPE OF SEPTIC WORK: NEW IN5TALLATI4N I:I REPAIR/ADDITION l I DESTRUCTIO I aNailabpelwithin 200 feetstern .) if public sewer is <br /> I T e,�J <br /> t v <br /> installation will serve: Residence d, Commercial_ Other <br /> Number of living units: Number of,bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> ❑ Type/Mfg Capacity <br /> SEPTIC TANK Y Method of Disposal , <br /> PKG. TREATMENT PLT. ❑ --�" <br /> Distance to nearest: Well <br /> Foundation Property Line <br /> ' - Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Property Line <br /> FILTER BED ❑ Distance to nearest: Well Foundation. P Y <br /> �� Size Number it <br /> SEEPAGE PITS l } Qepth! <br /> 1 Property Line ? <br /> SUMPS L-! Distance to nearest: Well Foundation <br /> s DISPOSAL PONDS .❑ <br /> F lication and that the work will be done in accordance'with San Joaquin county ordinances, state laws, and`'. <br /> f ! hereby certify that I have prepared this app• <br /> i rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies.tha following: "I certify that in the performance of the work for which this permit is issued, I signature <br /> she not <br /> I employ any person in such manner as to become subject to workman's compensation laws of California.`' Contractor's nsi$ub"ct t workmanng or jscompensa- <br /> k certifies the following: "'I certify that in the performance of the work for which this permit is issued, I shall employ pe 1 <br /> tion laws of California." <br /> The appf t must call for all required j pections. Complete rawing on reverse side. <br /> Title: Date: <br /> F S fined <br /> FOR DEPARTMENT USE ONLY <br /> Date_ — Area <br /> Application Accepted by f7rgcF fez <br /> Date Final Inspection by f <br /> Pit or Grout Inspection yG �/ r S / r <br /> Additional Comments: <br /> 7 <br /> r ❑ Sik 4fi6 6781 ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CK RECEIVED BYjDH�E PERMIT�NO.FEE AMOUNT DUE AMOUNT REMITTED CASHINFO 7 �7/�a <br /> + EH 13-24 MEV.t L <br /> EH 14-26 <br />