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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON 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. <br /> Job Address 1005 N. Durican Rd. s Linden City Lot Size PM <br /> parcel #105--1.10-15 <br /> Owner's Name John R tt0 Address 1005 N. Duncan Rd. Phone <br /> P111Yi8t1C@ Drillers Tuc . <br /> Contractor Address wP. O. Box 64s Lind-R—Rense No. 377923 Phone 887-»3554 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION= SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ('1 Public ❑ Other R Delta Depth of Grout Seal Type of Grout <br /> N41drrigation --Approx. Depth I ] Eastern Surface Seal Installed by _ C <br /> Repair Work Done ❑ Type of Pump -,Lib - H.P. 20hp State Work Done ..install-...II,P_TnT.- p <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f 1 REPAIR/ADDITION i I DESTRUCTION [ I (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 77- <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ' <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size �— <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS L� Distance to nearest: Well Foundation 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 /> 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."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 /> T t ca for wire�inspec��ionsCompleta rawing on reverse side. �j� <br /> Signe Title: F3'+r a- Pni- ��`'— Date: _4Z6Z$$ <br /> r FOR DEPARTMENT USE ONLY ��• <br /> Application Accepted by `!`/'L �7.- Data �`��� O C Area V <br /> Pit or Grout Inspection by Date Final Inspection by Datel© <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 INFO AMOUNT DUE ^AMOUNT REMITTED CK <br /> ,yC SH RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-241REV.iiKSY �r? s� � �(��� �// ��-�� ` v7 <br /> EH 14.26 ./ ��/ ��,/// <br />