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r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUiN' LOCAL HLu.LTH DISTRICT PERMIT NO. <br /> 1501 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 DATE ISSUED L <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) 1 <br /> permit <br /> l the <br /> Application is hereb mdtoithe SaniJoaquin LocelwHealthth DJoaquin CountyOrdinance co, 549tand/or <br /> rein <br /> forsewagesorlr <br /> de <br /> No. 1862forewell%pump <br /> application <br /> described. This <br /> and the Rules and Regulations of the San Joaquin Local Health District, <br /> Subdivision Name <br /> Job Address Phone <br /> p <br /> Owner's Name �a Address Phone A <br /> _ <br /> Contractor's Name <br /> License No. 2 <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELL WORK: NEW WELL ElpTHER <br /> PUMP INSTALLATION (❑ SYSTEM REPAIR ❑ U I <br /> DISPOSAL FLD. PROF. LINE <br /> SEWER LINES <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> AGRICULTURE WELL �_.�� OTHER WELL <br /> FOUNDATION <br /> CONSTRUCTION SPECIFICATIONS <br /> 1NTENOED USE TYPE OF WELL PROBLJ FM AREA Dia. CT Well Excavation <br /> F—lindustrial ❑Open Bottom ❑Manteca <br /> ❑ Domestic/Private ❑ Gravel Pack <br /> ❑Tracy Dia. of Well Casing <br /> ❑ Public [_1Other ❑Delta Type of Casing <br /> Irrigation Approx. ❑Eastern Specifications <br /> I <br /> Cathodic Protection Depth Depth of Grout Seal <br /> 4� ❑ <br /> 114{ ❑Geophysical Type of Grout <br /> ❑Other Surface Seal Installed by <br /> Ire H p State Work bone C7- <br /> k Repair Work Done E] Type of Pump <br /> 1Sealing Material (top 50') <br /> Well Destruction ❑ Well Diameter __ Filler Material (Below 50') <br /> Depth <br /> SEPTIC WORK: NEW INSTALLATION El REPAIR/ADDITION ❑ {No septic tank or seepage pit permitted if public sewer is C <br /> TYPE OF S available within 200 feet,} G <br /> Commercial Other <br /> installation will serve: Residence _ Lot size <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments <br /> SEPTIC TANK F-1 Type/Mfg Capacity Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Foundation Property Line <br /> SEWAGE SYSTEM Distance to neare t: Well <br /> DESTRUCTION Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Property Line <br /> � FILTER BED <br /> ❑ Distance to nearest: Well Foundation Dr <br /> Depth e ___�_ Size Number <br /> � SEEPAGE PITS ❑ P Foundation Property Line <br /> 4 <br /> SUMPS ❑ Distance to nearest: Well <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I haver prepared regulaapplication an that <br /> thenwork will <br /> Heald <br /> thDistr�ictcoordance with San Joaquin county <br /> tionsd this <br /> stat <br /> and <br /> ordinances, s theollowig: ,I that <br /> erformance of te <br /> ork <br /> or which this <br /> Home owner or licensed agent's signature cien such4mannernas to become subjectnh <br /> toworPkmant compensationwlawsfof California." <br /> permit is issued, I shall not employ any person <br /> llowing: "I certify that <br /> performance of the work for which <br /> contractor's hiring or sub-contracting signature certifies the falthe <br /> this permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> L The applicant must c 11 fr 1 re . ed inspections. Complete draw' on averse s' e• Date: <br /> Title: <br /> Signed X�/Yl" <br /> b`FOR PARTMENT USE ONLY ` Stk 466-6781 <br /> Area _��— ' <br /> ( Application Accepted by ❑ Lodi 369-3621 <br /> Additional Comments: Date _��� ❑ Manteca 823-7104 <br /> t Pit or Grout Inspection by Date -7� <br /> ElTracy 835-6385 <br /> Final Inspection by <br /> + to: Env' nmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 952 <br /> 01 <br /> Applicant - Return all copies <br /> f RECEIVED BY DATE PERMIT NO. <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED cQ <br /> INFO 10 <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />