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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 I the work herein described.This application is <br /> made H compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. � <br /> rt <br /> Job Address - � ,3 _ '� <br /> dv City — Lot Size PM <br /> Owner's Name <br /> Address' ! hone <br /> Contractor PVbtceDrillersMillingCj� <br /> u - <br /> ress �� License No. 72. 1-3 S.5' <br /> O <br /> TYPE F WELL/PUMP; NEW WELL <br /> 'PUMP INSTALLATION Phone <br /> WELL TION REPLACEMENT ❑ DESTRUC ❑ <br /> � SYSTEM REPAIR ❑ � <br /> DISTANCE TO NEAREST; SEPTIC TANK OTHER ❑ <br /> �--- - >. -t--�- , _ �� SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL r <br /> + `" - , , v, 0 <br /> 'INTENDED USE OTHER WELL tPITSTSUMPS <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial t iii Open Bottom If Manteca <br /> Dia. of Well Excavation. <br /> ❑ Domestic/Private ❑ Gravel Pack ��— Dia, of Well Casing � <br /> E3 Public ❑ Tracy Type of Casing_ SrF�L <br /> ❑ Other ❑ Delta Specifications <br /> � Depth of Grout Sea! Type of Grout <br /> X Irrigation �fL�gpprox. De th ❑ Eastern <br /> Repair Work Done ❑ Type of Pum M( Surface Seal Installed S <br /> Well Destruction ❑ Well Diametep H PJ'�L N rA/EState Work Done <br /> Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ ;No septic system permitted if public server is <br /> Installation will serve: Residence available within 200 feet.) - <br /> `- -"'- Commercial�, Other-. <br /> Number of livingunits: <br /> Number of bedrooms <br /> Character of soil to a depth of 3 feet: o <br /> SEPTIC TANK ❑ Type Water table depth � <br /> /Mfg Capacity <br /> PKG. TREATMENT PLT. ❑ No. Compartments <br /> '~) <br /> Distance to nearest: Well Foundation Method of Disposal <br /> Property Line <br /> LEACHING LINE EI No. & Length of lines <br /> FILTER BEDTota! length/size <br /> ❑ .Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS ❑ Depth - <br /> Size^" - Number <br /> a <br /> SUMPS_ __ ❑ Distanceeto.nearest:. . Well Foundtion <br /> DISPOSAL PONDS ~❑ _ Property Line <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 agents 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 pbrsons subject to workman's compensa- <br /> tion laws of California." <br /> The applica t must call fo al r q 'red inspections. Complete drawing on reverse side. .f <br /> Signed " <br /> Title: Date: <br /> FOR DEPA TMENT USE ONLYr <br /> Application Accepted by L.,/ <br /> Date �� 6 � �-h� Area a 2— <br /> Pit <br /> Pit or Grout Inspection by DateFinal I <br /> nspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ �' Env 13 Mant -7104 eca ;Applicant- Return all copies to: Environmental HelhPermit/Sr cess 1601 E. Hazelton Ae., P.O.P # <br /> Box 2009; Stk., CA 95201 <br /> I i }• ; <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO # <br /> -^y CASH RECEIVED BY DATE aPERMIT,'No.EH14-24SREV.t/95) '�� jlw <br /> EH 1426 <br /> P <br />