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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 /> Application is hereby made to the San Joaquin focal Health District for a permit to construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No.549`or age orN. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. )1 <br /> PM <br /> Z6�� ,�� �` � VlJ City Lot Size <br /> Job Address – • 0- <br /> Owner's Name <br /> C , Address Phone <br /> / K�I 4hJ -—Phone <br /> k (7 Address • License No \ <br /> Contractor <br /> TYPE OF WELL/PUMP: NEW WELL L7 WELL REPLACEMENT l- DESTRUCTION C1 <br /> t. ti PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ N <br /> SEWER LINES DISPOSAL FLD. LINE <br /> DISTANCE NEAREST: SEPTIC TANK PITS/SUMPS <br /> FO AGRICULTURE WELL OT ` <br /> 4 TION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA Dia. of Well Casing <br /> s ❑ industrial ❑ Open Bottom ❑ Ma Dia. of Well Excava r \ <br /> ecifications <br /> ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing <br /> — <br /> 0 <br /> Public ❑ Other <br /> l Ll Delta Depth of Grout Seal Type o \ <br /> I I Irrigation —.Approx. Depth i I Eastern Surface Seal Installed by r <br /> d H P State Work Done �V <br /> k Repair Work D Ll Type of Pump <br /> W ruction ❑ Well Diameter Sealing Material [top 501 1 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I.l REPAIR/ADDITION i I DESTRUCTION�j� (No septicem <br /> sy t 200 (eeft�ed if public sewer is � <br /> ! Installation will serve: Residence= Commercial— Other <br /> 4 <br /> Number of living units: Number of bedrooms +L <br /> Water table depth <br /> Character of soil to a depth of 3 feet:' <br /> SEPTIC TANK 0 TYP 9. <br /> e/Mi Capacity No. Compartments <br /> C <br /> PKG. TREATMENT PLT. ❑ IFMethod of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑' No. &Length of lines Total length/size G <br /> FILTER BED ❑ 'Distance to nearest: Well Foundation Property Line <br /> r SEEPAGE PITS f I Depth+ Size Number ` <br /> SUMPS Cl Distance.to nearest: Well Foundation Property Line 1 <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 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, t shall not <br /> I s to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> employ any person in such manner a <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 campensa <br /> tion laws of California." <br /> E The :pp <br /> te drawing on reverse side.Title: Date: <br /> Signd <br /> FOR DEPARTMENT USE ONLY i <br /> . Date ` 6�Ar-- <br /> / <br /> Application Accepted byPit or Grout Inspection byDateFinal Inspection byDate <br /> IF Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi '369 3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> t Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave'., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. e . <br /> CASH <br /> INFO (�Jf/� 1.Mot <br /> +.EH 13-24IREV�rin51 3J' `-'V 6 24 q1 <br /> - <br /> EH 14-28 <br />