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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH-;DISTRICT <br /> 1601 -E. HAZEL T ON AVE., STOCK TON, CA <br /> Telephone (209)-466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> oaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> Application is hereby made to the San J <br /> go or No. 1962 forhwell/pump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for sewa <br /> Local Health District, <br /> City Lot Size PM <br /> Job.Address <br /> w <br /> Phone <br /> Owner's Name Address J <br /> r <br /> s � nse No.�11111�-2Wone <br /> Contractor ' <br /> WELL REPLACEMENT,,❑ DESTRUCTION ❑ <br /> TYPE OF WELL/PU P: NEW WELL ❑ ''"*" OTHER ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ _ <br /> DISTANCE TO NEAREST: SEPTIC TAMC SEWER LINES <br /> DISPOSAL FLD."" PROP. LINE <br /> FOUNDATION AGRICULTURE WELL r OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL:.,, PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑_ Manteca Dia- of Well Excavation Specifications I <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> Delta Q <br /> l'1 Public 171 Other <br /> Cl epth of Grout Seal Type of Grout <br /> I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by - G <br /> ^ j <br /> Repair Work Done ❑ Type of Pump H P State Work Done <br /> Well Destruction O Welt Diameter Sealing Material (top 50'1 t: <br /> Depth Filler Material M o ') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 3 REPAIWADDITION l DESTRUCTION l I (No septic system permitted if public sewer is <br /> I <br /> available within 200 feet.) <br /> In will serve: Residence, Commercial_ Other I <br /> Number of living units: Number of bedrooms <br /> fj Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well <br /> Foundation Property Line # <br /> l Total length/size <br /> LEACHING LINE Cl No. & Length of lines t <br /> ❑ Distance to nearest. Well Foundation Property Line <br /> FILTER BED <br /> EEPAGE PIT I I Depth Size <br /> Nymber r <br /> PS <br /> L7 Distance to nearest: WellZA�E Foundation� Property Line k <br /> DISPOSAL PONDS <br /> I <br /> I hereby certify that I have prepared this application and that the work will be done in accordarice with San Joaquin county ordinances, state laws, an <br /> rules and regulations of the San Joaquin Local Health District ��t� I shall not <br /> Home owner or licensed agent's signature certifies the following: "L certify that in the performance of the work ftc m #+ nature <br /> employ any person in such manner as to become subject to workman's compensation Earns ss California."l Contras h i u ct g g <br /> certifies the following: "I certify that in the performance of the work for which this permits issued,1 shall, s subject to workman's compensa <br /> tion laws of California <br /> The applicant ust for require s ctions. Compl drawing on erse side. <br /> Signed <br /> Title: �� Date: <br /> OR DEPARTMENT USE ONLY <br /> . I • Date � rea v <br /> Application Accepted by _l ��' <br /> Final Inspection by ` Date <br /> Pit or Grout Inspection by� Date . <br /> Additional Comments: IZI <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy. 835 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hezelt6n Ave., P.O. Bax 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH ,`RECEIVED BY DATE PERMIT NO. <br /> .M <br /> � EH 13-24 MEV.11847--y-C <br /> EHt118�.. - - ----------- - . .. i <br />