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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 for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. �f,"P <br /> Job Address ,� . City ��It[1�E`�C/ Lot Size A� 'rA62-' PM <br /> P6ne3' 7� <br /> Owner's Name G�d 6,94,cN Address` = <br /> Contractor's Name d License -No. Phone` <br /> TYPE OF WELL/PUMP: •- ---NEW-WEL-L� -T�' <br /> WELL REPLACEMENT—E] DESTRUCTION 13 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC-TANK' SEWER LINES ,DISPOSAL FLD. PROP. LINE ; <br /> (� f FOUND" TA ION AGRICULTURE WELT?r t'+ OTHER WELL PITS/SUMPS <br /> v INTENDED USE -'"TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> �slndustrial' � ❑ Open Bottom EIManteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> of CasingSpecifications <br /> ElDomestic/Private F-1T Gravel Pack ❑ Tracy Type <br /> ❑ Public % El Other ❑ Delta Depth of Grout Type of Grout ;> * _� <br /> ❑ Irrigation ---Approx. Depth ❑ Easterner Surface.Seal Installed by r <br /> 5 : , Jr <br /> Repair Work Done �❑ Type of Pump:, H.P .' State Work Dane <br /> Well Destruction ❑ Well Diameter' [:Sealing Material {top 50'1 <br /> ° r <br /> Depth Filler Material [Below 50'1 } <br /> r <br /> TYPE OF,SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION X ,DESTRUCT{ON ❑ (No septic system permitted if public sewer is <br /> xs - - _ available within 200 feet.) <br /> Installabo wi!serve: Residence ,Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> .. . -- - _ .. Water table depth <br /> Character otsoil to a dep—th of 3 feet: <br /> SEPTIC TANK ' Type/Mfg Capacity. No. Compartments!C] 1 -- <br /> .� .� <br /> PKG. TREATMENT PLT..O Method of Disposal <br /> Al <br /> Distance to nearest: Well Foundation Property Line <br /> 0 <br /> r / <br /> �( <br /> — ' e <br /> LEACHING-LINE No. & Length of lines Total lengthlsiz <br /> X t G <br /> FILTER BED Ll Distance to nearest: Well !2 Foundation� Property Line <br /> --x <br /> K <br /> i SEEPAGE PITS � Depth _—_L-S7_ Number <br /> —Size � � <br /> SUMPS Cl Distance to nearest: Well-fes— Foundation - Property Line <br /> DISPOSAL PONDS ❑ <br /> hereby certify that I have prepared this application and that the work will 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 /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub contracting signature <br /> certifies the followi :"I certify that in the pert ante of the work for whichs p <br /> this is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of Calif nia." s <br /> I The applica t II for all Auired in ctions. Complete drawing on averse• ide. z <br /> Si neo Title: `Date: <br /> g <br /> FOR D PARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> 77 <br /> Pit or Grout Inspection by Date_6 Final Inspection by Date <br /> rA <br /> I <br /> I Ad -tional Comments: <br /> 46781 ❑ Lodi -369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 6385 <br /> 66- <br /> I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUEAMOUNT REMITT .. RE <br /> ED '+ CK• CEIVED BY Q= <br />