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777 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 Local Health District fora /or the_ described. <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage No. 862 for andinstalhe Rules and Regulationsof the S p <br /> Local Health District. This application is <br /> ran Joaquin ' <br /> Job Address <br /> City Lot Size PM <br /> Owner's Name 1-Address I <br /> hone y Z. <br /> Contractor Address t3�5 /e <br /> TYPE OF WELL/PUMP: License No. 3 Phone <br /> NEW WELL ' WELL REPLACEMENT 0 DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK / OTHER ❑ <br /> t4s� SEWER LINES DISPOSAL FLD: I <br /> FOUNDATION AGRICULTURE WELL PROP. LINE <br /> INTENDED USE OTHER WELL PITS/SUMPS <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca <br /> Dia, of Well Excavation Dia. of Well Casing <br /> Domestic/Private �I Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Other EJ Delta Depth of Grout Seal s <br /> 0 Irrigation —._Approx.;Depth ❑ Eastern Type of Grout <br /> Repair Work Done ❑ T Surface Seal Installed by <br /> Type of Pump N.P. State Work Done <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material (top 50') � <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REP AIR/ADDfnON ❑ DESTRUCTION ❑ INo septic P system permitted if public sewer is <br /> Installation will serve: Residence Commercial available within 200 feet.) <br /> 7:J4. _Other _ . <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: ' <br /> SEPTIC TANK 0 Type/Mfg I t Water table depth <br /> PKG. TREATMENT PLT, ❑ Capacity No..Compartments <br /> Distance to,nearest: Well ' Method of Disposal I <br /> Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines <br /> FILTER BED 0 Distance tonearest: Well — Total length/size <br /> Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size <br /> l �� Number <br /> SUMPS E3 Distance to�lnearest: Well Foundation <br /> DISPOSAL PONDS 0 Property Line <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and W <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 his permit is issued, 1 shall not <br /> employ any person g such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the following: "t certify that in the performance of the work for which this <br /> tion Paws of Cali ornia." permit is issued,1 shall employ persons subject to workman's compensa- <br /> The applicant ust call for all requi d inflections. Complete drawing on re erse side. <br /> Signed 1 <br /> Title: Date: (o Z <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date Area <br /> Pit or Grout Inspection b�27 <br /> Date Final Inspection by g� <br /> Date <br /> Additional Comments: <br /> Cl Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M <br /> 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 K# J <br /> INFO RECEIVED BY DATE <br /> r �g� PERMiT•'NO. <br /> + EH 13-24(REV,i is s) <br /> E '��J�^ H <br /> li 74-28 <br /> 2 <br />