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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA T . <br /> E Telephone (209) 466-6781 SCO <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED DATE ISSUED <br /> (Complete in Triplicate) <br /> 7 Application is hereby made to the San Joaquin Local Health District for a permit <br /> p R described• This application ins made in compliance with San Joaquin County0 dinanceconNo. 549tfoordsewagesorlNo.the 1862rfor ewell/pump <br /> and the Rules and Regulatio s of the San Joaquin L caI Health District. <br /> Joh Address <br /> Subdivision Name <br /> Owner's Nam <br /> Y dress r Phone —Z <br /> Contractor's Name <br /> License No. <br /> Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL <br /> E] WELL REPLACEMENT ❑ DESTRUCTION [J— <br /> I PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> PITS/SUMPS <br /> j INTENDEp USE TYPE OF WELL PROBLEM AREA ~� <br /> Industrial CONSTRUCTIONPE <br /> SCIFICATIONS <br /> ❑Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private Gravel Pack T <br /> 1 ❑ public ❑ rac Y Dia, of Well Casing <br /> i <br /> LJ Irrigation ❑Other ❑ Delta Type of Casing <br /> I Approx. ❑ Eastern <br /> [� Cathodic Protection Depth Specifications <br /> ❑Geophysical Depth of Grout Seal <br /> ❑Other Type of Grout <br /> Repair Work Done ❑ Type of Pump Surface Seal.Installed by <br /> --�� H•P• State Work Done <br /> Well Destruction Well Diameter Sealing Material (top 50') <br /> 1 � <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION <br /> ❑ (No septic tank or seepage pit permitted if public sewer is �' <br /> Installation will serve: Residence Commercial Other available within 200 feet.) <br /> Number of living units: _ __ Number of bedrooms <br /> __L_ Lot size <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANKWater table depth <br /> Type/Mfg Capacity LZL7 D No. Compartments Z <br /> PKG. TREATMENT PLT. [� Type/Mfg -� p y Method of Disposal <br /> Ca acct <br /> I <br /> Distance to nearest: Well �- Foundation _AL_L&_ Property Line <br /> LEACHING LINE F No. & Length of line i <br /> To length/size Z y <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> Property Line \ <br /> SEEPAGE PITS Depth <br /> F.' <br /> SUMPS � p Size Number r _ <br /> Distance to nearest: well <br /> DISPOSAL PONDS — 00 Foundation Property Line <br /> ❑ <br /> F ' <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county <br /> ordinances, state laws, and 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 <br /> permit is issued, I shall not employ any person in such manner as to became subject to workman compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> 4 this permit is issued, I shall emp oy persons subject to workman's compensation laws of California." <br /> The <br /> Signed appl ' ant must 1 <br /> all re ed inspe ions. Complete d in on reverse side. <br /> Title: Date: <br /> pl cation Accepted by 0 DEP MENT USE ONLY <br /> Area _ ❑ Stk 466-6781 <br /> Additional Comments: <br /> Pit or Grout Inspection by ❑ Lodi 369-3621 <br /> Date Manteca 823-7104 <br /> _1 Final Inspection by Datel'1,STracf <br /> Applicant - Return all copies to: EnvironSices 1601 E. Ave,, P❑.O. Boxy 200935Stk8,5 <br /> mental He thPermit/ ery <br /> CA 95201 <br /> FEE BASE HAMOUIN7TDUE AMOUNT REMITTED RECEIVED BY <br /> INFO DATE PERMIT No. <br /> �5 a� 1�•._ �Z2- _7d <br /> i EH 13-24 REV. 10/82 ��11 { <br /> y 14-26 �c�. � Sv �� �� 10/82 500 p <br />