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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 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> install the work <br /> here <br /> . This <br /> cation is <br /> Application is hereby made to the San CoJoaquin OrdinancHealth e No.Distrfor sewage permit <br /> t 1862 for Ildpump and the flutes and 1Regulations of the San r Joaquin <br /> made in compliance with San Joaquin N <br /> Local Health District. y <br /> Job Address <br /> r— v City Lot Size PM <br /> Phone <br /> ddress <br /> Owner's Name -2111 <br /> f Phone <br /> Contractor <br /> Address fir enser" - <br /> TYPE OF WELLIPUMP: LJ <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTflUCTION <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ NE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES .�--- <br /> DISPOSAL FLD._—�=�R <br /> FOUNDATION AGRICULTURE WELL OT t1VELL PITSISUMPS <br /> E INTENDED USE TYPE OF WELL PROBLEM AREA CONSTR SPECIFICATIONS Dia of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca of,Well Excavation <br /> Type of Casing Specifications � <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy yp Type of Grout <br /> f 1 Public F) Other Cl a Depth of Grout Seal <br /> Repair <br /> Irrigation —Approx. De_ l I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ of Type p <br /> H.P. State Work Done_ <br /> Well Destruction ❑ Diameter Sealing Material (top 50'1 <br /> Depth Filler Material (Below 50'1 <br /> { TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRIADDITION t I DESTRUCTIO aNailabpertc within m PC <br /> 200 feetirmltyed if public sewer is <br /> r r <br /> i Installation will serve: Residence_ Commercial ter <br /> Number of living units: Number of bedrooms <br /> •--•-° Water table depth <br /> Character oI to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> 1 PKG. TREATMENT PLT. ❑ �~ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ' LI No. & Length of lines Total length/size <br /> t <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PUTS I I Depth Size _ Number <br /> SUMPS El Distance to nearest: Wel! Foundation Property Line <br /> i DISPOSAL PONDS ❑ <br /> i the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and that <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 shalt 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 t call for all required inspections. Complete drawing on <br /> i Signed X <br /> Title: Date: <br /> ( FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date <br /> Pit or Grout Inspection y <br /> Date Final Inspectionby Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95261 <br /> FEE CK RECEIVED BY DATE PERMIT.NO. <br /> Fk INFO �AMOUNT/DUE AMOUNT a-CASHy/� <br /> h <br /> ♦ EH 13-24(REV.1/ 5Y y!J�V ""O f `' �/'� 1 � � /�• <br /> Eli 1428 <br />