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" <br /> :N <br /> 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 /> r application is <br />� - I <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct well/pump <br /> install the work herein described.This app <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the RulesZ0Regulations the San Joaquin <br /> Local Health District. 4 <br /> City Lot Size PM <br /> Job Address <br /> .Z� i!}/I� Address Phone <br /> Owner's Name ; <br /> / � Phone <br /> Contractor's Name _ License No. l� C� <br /> - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> ,'PUMP INSTALLATION ❑ SYSTEM REPAIR 1: OTHER ❑ CAJ <br /> DISTANCE TO NEAREST:, SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> ; FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> TYPE OF j�ELLPROBLEM AREA CONSTRUCTION SPECIFICATIONS' <br /> INTENDED USE i Dia. of Well Casing <br /> ❑ Industrial `❑ Open Bottom ❑ Manteca Dia. of Well Excavation 4 <br /> . y Specifications <br /> ❑ Domestic/Private EJGravel Pack ElTracy type of Casing Type of Grout <br /> El Public <br /> [I other ❑ Delta Depth of Grout Seams - <br /> ❑ Irrigation <:.-_J4pprox. Depth ❑ Eastern Surface Seal Installed by , �� 1 <br /> -' H P 5tate_Wor. ne <br /> Repair Work Done El Type of Pump ' �L.. <br /> Well Destruction ❑ Well Diameter. Sealing Material {top 501 <br /> Il <br /> /Depth j Filler Material (Below 501`.- —_` <br /> er <br /> TYPE OF SEPTIC WORK:E NEW INSTALLATION ❑ REPAIR/ADDITI:ON O DESTRUCTION ❑ (No <br /> ail'septicri hinem20' feeitted if public sewer is <br /> Installation will serve: Residence / Commercial_ Other a -"I <br /> J <br /> Number of living units: __ Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: -Z <br /> T IMf Capacity G41 No. Compartments <br /> SEPTIC TANK >L ype g f } ` Method of Disposal <br /> PKG. TREATMENT PLT. ❑ a <br /> Distance to nearest: Well Foundation_/ Property Line f <br /> t° 'f - <br /> No. & Length of lines �' Total length/size _ <br /> LEACHING LINE � E <br /> FILTER BED ❑ Distance to nearest:, Well 3 Foundation.�2t— Property Line <br /> 3 i <br /> ' SEEPAGE PITS Oif- Number Depth .�- r -Size l i¢ <br /> SUMPS ❑ Distance to nearest: Well Foundation -Property Line <br /> DISPOSAL PONDS ❑ 3 <br /> hereby certify that I have prepared this-application'and that the work Twill 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, I shall not <br /> manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> employ any person in such <br /> certifies the following:"I certify <br /> manner,thain 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" -�r <br /> { <br /> The applicant mu c 6 1 equir d inspectio s. Co late drawing on reverse side. <br /> s .5 s <br /> "� Title: Date: <br /> Signed <br /> F ry� FOR DEPARTMENT USE ONLY <br /> e 4� <br /> QFr <br /> ation Accepted by DatArea <br /> P' Grout Inspection by <br /> ' Date ✓ Final Inspection by Date <br /> � <br /> Additional Comments: lZ�r <br /> L3 Stk 466-6781 11 Lodi 369.3621 ❑ Manteca 823-7104 171 Trac 835-6385 <br /> 1 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> I <br /> i . <br /> CK# RECEIVED BY DATE PERMIT NO. <br /> I1 IFEE <br /> NFO AMOUNT DUE AMOUNT REMITTED CASH _ <br /> F + EH 4324 SRE°V.10!83) <br /> EH 1426 <br />