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t <br /> 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 YEAS-FROM DATE ISSUED' <br /> (Complete in:Triplicate) <br /> t and/or install the work herein described.This application is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construe <br /> unty Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> made in compliance with San Joaquin Co <br /> l Local Health District. :4 4 r. <br /> City i e z PM `t <br /> 1, Job Address _ <br /> � Y Address-, - <br /> Owner's Name •— Phone." <br /> f. <br /> •`" 3�Ve C License No. <br /> I t �� q� Address Phone <br /> Contractor---- - -s= <br /> - - - - -"-PAIR ❑ OTHER ❑- - DESTRUCTION 'D v"-`"�'•.'T.'-..-- <br /> -T`(PE OF <br /> WELL --�= .__NEW-�WEL•L❑-�-^T"" WEL-L REPLACEMENT ❑y <br /> SYSTEM RE 'z <br /> PUMP INSTALLATION ❑ ' <br /> hDISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST:SEPTIC TANK SEWER LINES <br /> 3 ' FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well ExcavDia. of Well Casing <br /> -» <br /> T e of Casin 'Specifications <br /> ❑ Domestic/Private © Gravel Pack El Tracy yp 9 Type of Grout <br /> ' ❑ Other I ❑ Delta Depth of Grout Seal yp <br /> ❑ Public, <br /> ` s r�pplox. Depth ❑ Eastern Surface Seal Installed by <br /> ❑ Irrigation n j ;j w 14 State Work Done <br /> Repair Work Done ❑ Type of Pump H.P. !� <br /> t ' 1NeIIDiameter Sealing Material Itop 50') U <br /> Well Destruction , *❑ ," }, f <br /> Depth 1 Filler Material (Below 50') U <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION PAIRIAODITION Cl.- DESTRUCTION Llavailable septic <br /> permitted if public sewer is <br /> wth5n�200 feet.) <br /> Installation will serve: Residence Ai <br /> Commercial Other <br /> Number of Iiving�Units: Number of bedrooms_ g <br /> t Water table depth <br /> Cha atter of soil to a depth of 3 feet: ; _ <br /> F r pacity No. Compartments <br /> SEPTIC TANK C�ype/Mfg ;5 a i , <br /> � Method of Disposal <br /> PKG. TREATMENT,PLT. ❑ <br /> t �Fdundation� t Property Line <br /> Distance to nearest: Well �. <br /> _ t <br /> TotatViridth/size <br /> LEACHING LINE f�fO�i & Length of lines gg fi .,\ <br /> FILTER'BED ❑ Distance to nearest: Well ' �- Foundation I Pfoperty Lme <br /> I SEEPAGE PITS ❑ Depth Size? Number' t 1 <br /> SUMPS ❑ Distance to nearest: Well Foundation PAoperty dine '- { <br /> - M ' -�. . . . , <br /> DISPOSAL PONDS Q i €' "'`W F <br /> ! hereby'certify that i have prepared this application and that the work will be done'in'ac^�ord�a wFf� San"Joaquin county ordinance state laws, and <br /> rules and'regulations of the San Joaquin Local Health District. - . 1 <br /> Home owner or licensed agent's signature certifies the following: "I certify that.m the performance of the work for which this permit4s issued,=1.shall not <br /> employ any person in such mannerasto becorne sbbject to workman's compens3tio�t"ti av+ of-California: <br />