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APPLICATION TOR.PERMIT <br /> SAN JOAQUIN LOCAL,HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781' <br /> PERMIT EXPIRES 1 YEAR.FROM DATE ISSUED' <br /> I (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.r <br /> Job Address j L City.. S Y cl t Size / PM <br /> K Owner's Name i Address phone 93/Wo <br /> 1 <br /> i <br /> Contractor's NameLicense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT,❑ DESTRUCTION.❑ +++ <br /> PUMP INSTALLATION. d:.r �SYSTER RE.' C] ` •r <br /> -� -�.'",�'' P 3�-' _.. .t. '"OTHER Ll <br /> DISTANCE TO NEAREST:-SEPTIC TANK- SEWER LINES._`y r -.DISPOSAUFLD. - PROP-t—UNE 90 <br /> '� <br /> FOUNDATION ,' Q AGRICULTURE WELLt OTHER WELL PITS/SUMPS <br /> INTENDED USE iYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. f If EXXcavation bio. of Well Casing <br /> Domestic/ E'/ <br /> �+. 0(2 <br /> ,,ravel Pack ❑�Tracy Type of;;l;asingew � Specifications <br /> A' {, 1❑ Other 17� Delta Depth of Grout Seal ' <br /> ❑ Irrigation Ty a of Grout 7�_ <br /> 0 Q Approx. Depth Eastern Surface Seal Installed by I <br /> Repair Work Done ❑ Type of Pump .5-c& H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material•(top 50') <br /> Depth Filler Material {BeGw 50'1 f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION p REPAIR/ADDITION'.❑ DESTRUCTION ❑ (No sep72e <br /> permitted if public sewer is <br /> --- - = " available feet.) E <br /> Installation will serve_" Residence_ Commercial OjherNumber of living units: Number of bedroomsif A <br /> Character of soil to adepth of 3 feet: i WepthSEPTIC TANK ❑ Type/Mfg - Capacity NomentsPKG. TREATMENT PLT. ❑ i r s �' MisposarDistance to nearest: Well Foundation Property _LEACHING LINENo. &,Length of lines Total len <br /> -..� length/size <br /> FILTER BED ❑�" Distance to nearest: Well - '- Foundation <br /> -Property Line <br /> SEEPAGE PITS ❑'*Dep'th Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS El Foundation <br /> . <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin coun <br /> rules and regulations of the San Joaquin Local Health District. - - -= �=tet .,> Y.. <br /> Home owner or licensed ty ordinances, state laws, and <br /> ed agent's signature certifies the following: "I certify that in the performance of the work for which this <br /> employ an Pe permit is issued, i shall not <br /> p y penton in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> tion'laws of California." <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 compensre <br /> The applica us all for all requi d ' spect' ns. C plete drawing on reverse side. <br /> Signed / Title: <br /> Date: <br /> 1 , t y,h• V - <br /> DEPARTMENT USE ONLY 1 <br /> Application Accepted b _ ` s � <br /> Date Area ? <br /> Pit or Grout Inspectio y Date_ Final Inspection by Date <br /> Additional Comments: <br /> ❑ 5tk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 836-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009;t5tk., CA 95201 <br /> FEE AMOUNT DUE '. AMOUNT REMITTED' GK <br /> INFO CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24(REV.10/83) ' +-y / p g`. G <br /> EH 1426 f <br />