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: <br /> APPLICATION FOR PERMIT 'S <br /> pl SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) application is <br /> r forsewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin <br /> eieb made to the San Joaquin Local Health Disgtoct for apermit to construct and/or install the work herein described. This <br /> Application is h Y Ordinance No.54 <br /> made in compliance with San Joaquin County <br /> Local Health District. , PM f-- <br /> �{� City Lot Size � <br /> Job Address '-' phone "j <br /> 6 <br /> Address <br /> Owner's Name Phone <br /> License No. <br /> + <br /> Address <br /> Contractor DESTRUCTION ❑ <br /> WELL REPLACEMENT ❑ <br /> NEW,WELL ❑ OTHER ❑ <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ <br /> PUMP INSTALLATION ❑ SEWER LINES DISPOSAL FLD. PROP. LINE <br /> �— —.— <br /> DISTANCE TO NEAREST: SEPTIC TANK �— AGRICULTURE WELL OTHER WELL p1T51SUMPS <br /> FOUNDATION �� <br /> USE T <br /> INTENDED YPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> l LJ Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> 5 Industrial Type of Casing "f -_ = r p <br /> ❑ Tracy 1. Type of.'Grout ------ <br /> ❑ Domestic/Private ❑ Gravel Pack Fl Delta <br /> Depth of Grout Seal <br /> Cl Other <br /> f'1 Public Surface Seal Installed by <br /> I I Irrigation --Approx. Depth I I Eastern State Work Done <br /> �� H.P. �� F <br /> Repair Work Done ❑ Type of Pump Sealing Material (top 501 " <br /> r Well Destruction ❑ Well Diameter <br /> + Depth Filler Material (Below 50') <br /> Iailable within 200 feet-) <br /> ' TYPE OF SEPTIC WORK: NEW INSTA}LLATION�1 REPAIRlADDITION l 1 DESTRUCTION lNo septic system permitted if public sewer is <br /> av <br /> Commercial Other�_�� 11 <br /> installation wilt serve: Residence ; �r. i <br /> I Nldinber of bedropms <br /> Number of living units: I ., Water table depth' <br /> Character of soil to a depth of 3 feet: Capacity� No. Compartments <br /> SEPTIC TANK ❑' Type/Mfg Method,of Disposal <br /> PKG. TREATMENT PLT. L7 t- Foundation — Property Line j <br /> Distance to nearest: Well <br /> I <br /> f Total length/size <br /> LEACHING LINE ❑ No. & Length of lines_ ;. Property Line <br /> I FILTER BED <br /> ❑ Distance to nearest.' --Well Foundation <br /> i Number <br /> SEEPAGE PITS 11 Depth i Size € Property Line <br /> SUMPS Ll Distance to nearest: Well�- <br /> Foundation <br /> i <br /> DISPOSAL PONDS ❑ 1 <br /> L <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, an <br /> rules and regulations of the San Joaquin Local Health District. work f <br /> Home owner or licensed agent's signature certmiiiesub subjecttowok man'srtcompensation lify that in the aewsoomCalifo�n ahg Contractor's hiring ngr or sub-contractingls gns permit is issue latu�e <br /> employ any person in such manner as to become I <br /> r certifies the following: "1 certify that in the performance of the work for which this permit I�issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California.' I <br /> The applicant mus a for all required_inspections..Complete-drawing,on reverse side.—, Date: � a <br /> Title: i <br /> l Signed X <br /> FOR DEPARTMENT USE ONLY Q� ' <br /> EDate Area - <br /> Application Accepted by.. Date <br /> Date <br /> Final Inspection by <br /> Pit or Grout Inspection by i int e,es � �� ill <br /> u&/ <br /> A ditianal Comments: _ - - F. J <br /> 4b6_6A <br /> • O Lodi'369-3621 ❑ Manteca 823 104 ❑ Tracy y,835-6385 <br /> plicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton AvILI e., P.O. Box 2009, Stk., CA 452 <br /> t <br /> �. �PERM1T'NO. <br /> FEE AMOUNT REMITTED CASE{ <br /> Z <br /> Y: DATE <br /> INFO AMOUNT DUE '� _ �} <br /> a EH 13-24 SREV.,/n51 <br /> rr« EH 14-26--..,� <br />