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� S <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA r 1 <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is heieby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> or No. 1862 far welllpump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage <br /> Local'Health District. <br /> `, Cit Lot Size . PM <br /> Job Address <br /> Owner's Nam Address <br /> 7 _,J Phone <br /> Contractor <br /> �tAddress License No. Phone <br /> td <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 1-1DESTRUCTION1- <br /> PUMP INSTALLATION F1SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST::SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial w ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack 171 Tracy Type of Casing Specifications <br /> FI Public171 <br /> Other ❑ Delta Depth of Grout Seal Type of Grout <br /> —.— <br /> I I Irrigation —.-Approx. Depth i I Eastern Surface Seal Installed by <br /> ► Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> r <br /> Weil Destruction ElWell Diameter Sealing Material {top 501 <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I iREPAIR/ADDITION I 1 DESTRUCTION INo septic system permitted if public sewer is <br /> available within 200 feet.) <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 ❑ _Type/Mfg Capacity No. Compartments <br /> l PKG. TREATMENT PLT. ❑ Method of Disposal v a <br /> Distance to nearest:" Well Foundation Property Line <br /> I <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines <br /> i. <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I. Depth Sire Number <br /> SUMPS ❑ Distance to nearest: Well Foundation 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 Di'trict. <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 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 permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant call for allr 0 d inspecU Complete drawing on reverse side. ' <br /> Signed <br /> Title: Date: <br /> i <br /> • FOR DEPARTMENT USE ONLY <br /> Application Accepted by __ Date ` , Area t <br /> Pit or Grout Inspection by Date Final Inspection by s' ate <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104,/ ❑Tracy 835-6385 oZ <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. G--. <br /> HaazIt Ave., P�Box 2009, Stk., C 95201 <br /> [rJ1� <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO _ <br /> ♦.EH13-241REV.�1A5) '7I- _7S–i 6 /� <br /> EH 14-2a <br />