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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E, HAZELTON AVE., STOCKTON, CA l <br /> Telephone (209) 466-6781 <br /> PERMIT.EXPIRES 1 YEAR FROM DATE ISSUED,' <br /> (Complete in Triplicate) <br /> 1a rmit to construct and/or install the <br /> Application is hereby made to the San JoaquinLocal Health District for pe <br /> 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,Ryles and Regu rations of the San Joaquin <br /> Local Health District. I <br /> CL� L _L1 `lCity Lot Size PM <br /> Job Address r �,� s �.��" � '•�' .' '" jhn,- S1�4 <br /> g�p" cfd "e-k-CBY Phone <br /> Owner`s Name � ': AddressContractor PUW3s�i0elkllbesDrlllireCO%d ess .�- '� License No. 22 P <br /> TYPE OF WELL/PUMP: NEW WELL )C WELL REPLACEMENT ElDESTRUCTION ❑ ' <br /> PUMP WSTALLATION' SYSTEM REPAIR El OTHER 1. <br /> DISTANCE TO NEAREST: SEPTIC TANK �O�/ SEWER LINES DISPOSAL FLD. PROP. LINE <br /> —� <br /> -FOUNDATION^- �'� �- `AGRICULTURE WELL'='�"=-'�!" `OTHER=WELI= --� PITS/SUMPS <br /> f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIbN SPECIFICATIONS' <br /> k Oen Bottom ❑ Manteca Dia. of Weli Excavation Dia. of Well Casing <br /> ❑ Industrial p <br /> t Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing S f@e-1 Specifications <br /> 1 SeL Type of Grout J a G <br /> ❑ Public ❑ Other C3 Delta Depth of Grout Seal �� <br /> X Irrigation --Approx. Depth Ll Eastern <br /> Surface Seal Installed by 4 <br /> Repair Work Done ❑ Type of Pump — t - H-P• State Work Done <br /> Well Destruction L) Well Diameter Sealing Material (top 50'1 <br /> 1 <br /> Depth / Filler Material (Below 501 ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence�' Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity " r No. Compartments <br /> Method of Disposal <br /> PKC. TREATMENT PLT. ❑ ;_ <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines - Total length/size <br /> FILTER BED El Distance to nearest: Well Foundation Property Line r <br /> SEEPAGE PITS ❑ Depth; <br /> Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation t Property Line - <br /> DISPOSAL PONDS ❑ - ' <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, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> f 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 Cal'rfornia." Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify that in 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 - <br /> The applica ust,call fo el a red inspections. Complete drawing on reverse side. n p <br /> i �� <br /> Title: Date: <br /> Signed _ <br /> u FOR DEPARTMENT USE ONLY <br /> Date /6 Area & <br /> Application Accepted by —?Ir' y� <br /> Pito Grout nspection by Date y ` Final Inspection by �� - ate�O <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lath 369-3621 ❑ Manteca 82:3-7104 ❑ Tracy 835-6385 <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 =CASH <br /> DATE PERMIT"NO- <br /> INFO <br /> \:EH <br /> H1&24SREV.t/a5}1426 � O a _ - <br />