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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZ--L—FQN�AVE., STOCKTON, CA <br /> Telephone '( 09} 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate)- <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in compliance with SanJoaquinCounty Ordinance No, 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> City S O Lot Size PM <br /> Job Address <br /> ' LA A Phone <br /> Owner's Name �{ Address " <br /> 57 <br /> Address r <br /> Contractor Li ense No. <br /> G. Phone <br /> TYPE OF WELL/PUMP: NEW WELL IV/ WELL REPLACEMENT DESTRUCTION <br /> :s t <br /> PUMP INSTALLATION iS SYSTEM' EP VR"i��"`" """`"""'$'OTH R ❑ <br /> Fi '1 r--� I <br /> r -� 't" DISPOSAL FLD.&Z PROP. LINE �. C I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> FOUNDATION AGRICULTURE'WELD . t:OTHER•WELt } r PITS/SUMPS .3 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f <br /> t Industrial oj <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Gasing' € <br /> i i e <br />_. Q Domestic/Private OI�Gravel Pack ❑ Tracy Type of Casing _ T Y Specifications f <br /> (RePublic Cl Other 17Bid <br /> 0 to Depth of Grout Seal- Type of Grout <br /> I I IrrigationQ.lApprox. Depth l astern Surface Seal Installed by I <br /> Repair Work Done L1 Type of Pump _1).v� r H.P. fir_ _ - State Wok Done_ } <br /> Well Destruction Well Diameter l Z Sealing Material (tap 50'1 ��- F <br /> Depth N-E1 Filler Material (Below260') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION t DESTRUCTION-1'l INo septic system permitted if public s6weftis <br /> available;within 200 feet.) or <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms ! '^- <br /> 1Nater table depth r <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK 171 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 171Method o1 Disposal <br /> x <br /> Distance to nearest: Well Foundation Property.Line ti <br /> Total len th/size r <br /> LEACHING LINE ❑ No. & Length of lines g <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS_ I i Depth - Size Number <br /> SUMPS .f ❑ Distance'to near4k: Well Foundation Property Line s <br /> DISPOSAL POIVDS� ., ❑ �f I i T <br /> I hereby certify thMA have.prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, andt' <br /> r rules and regulations 11;'the San.'Joaquin-Local Health District. f + <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 n'ot, � <br /> I � �+aritpioyrany per uch manner as to be coriersubject`o w r-man's compensation laws of California."Contractor's hiring or sub-contracting signaturefa <br /> s r <br /> ,certifies the Ilowing: certify that-.in the`pe ordnance of the work'or which this perrrlit is issued, I shall employ persons subjec o work n's compen Ya <br /> {lon,laws, f California." ., t a <br /> '�✓"r , , on re de. { ` <br /> E The appli ant, st l all a' Plete;tlrawin 9 <br /> Signed X Title: _. <br /> FO� .DEPARTMENT USEZNLY <br /> �� <br /> Application Accepted by. j - w> Date Area <br /> Date_ <br /> I Pit or Grout Inspect by,-, - Date "' Final fnsectio bn y <br /> p <br /> Additional Comments: <br /> ! Stk 466.6781 Lodi . 369-3621 "i:C Mariteca�823-7104 13-Vac <br /> LJEly7835--tMS <br /> Applicant - Return all copies to: Environmehtal Hath Permit/Se vices 1601 E. Hazelton A�6.�,P.O. Box 2009, Stk., CA 95201CK " r� <br /> FEE AMOUNT DUE AMOUNT REMITTED f,CA$H„ RECEIVED BYE PATE P M1T'NO. <br /> INFO t <br /> j®� `. ! .r <br /> EH 13211REV.tin51 Z05 A <br /> EH 1428 ;.r <br />