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Application is hereby made to <br />described, This application <br />and the Rules and Regulations <br />Job Address /_,/-ia <br />Owner's Name <br />Contractor's Name <br />TYPE OF WELL/PUMP WORK: <br />PUM <br />DISTANCE TO NEAREST: SEPTIC <br />APPLICATION FOR PERMIT <br />SAN JOAQUiN LOCAL HLALTH DISTRICT <br />1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br />Telephone (?Cg) 466-6781 <br />DATE ISSUE <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. <br />(Complete in Triplicate) <br />the;San Joaquin Local Health District for a permit to construct and/or install the work herein <br />is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br />of the San Joaquin Local Health District. <br />bdio Sion Name <br />Ad ess f Phone <br />License No. Phone�3%l� <br />i <br />NEVJ WELL [� WELL REPLACEMENT E] <br />P INSTALLATION SYSTEM REPAIR U <br />TANK 1 SEWER LINES <br />FOUNDATION I AGRICULTURE WELL <br />DESTRUCTION <br />OTHER <br />DISPOSAL FLD. PROP. LINE <br />OTHER WELL _JZ�)"'— PITS/SUMPS <br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />I� Indus ial — penlBottom EJ Manteca Dia. of Well Excavation <br />omestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing <br />�] Public C1 Other Delta Type of Casing <br />V Irrigation Approz. Eastern <br />Depth Specifications <br />Cathodic Protection Depth of Grout Seal 41 <br />Geophysical Type of Grout y . <br />j� Other <br />Surface seal Installed by <br />Repair Work Done ❑ Type of Pump �- H.P. 3 State Work Done <br />.y <br />Well Destruction ` L Well DiameterF �� Sealing Material (top 50') — <br />Depth }� Filler Material (Below 50') <br />TYPE OF SEPTIC WORK: NEW INSTALLATION L{ REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is <br />available within 200 feet,) <br />Installation will serve: Residence Commercial Other <br />• <br />Number of living units: Number of bedrooms Lot size <br />Character of soil to a depth of.,13 feet: Water table depth <br />I <br />SEPTIC TANK Type/Mfg Capacity No. Compartments <br />PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br />SEWAGE SYSTEM Oistance to nearest: Well Foundation Property Line <br />DESTRUCTION F _. <br />LEACHING LINE Lj No. & Length of lines Total length/size <br />FILTER BED Distance to nearest: Well Foundation Property Line <br />SEEPAGE PITS Cj Depth I Size Number <br />SUMPS Cl Distance to nearest: Well Foundation Property Line <br />DISPOSAL PONDS ED <br />r <br />I hereby certify that I have prepared -this application.and that the work will be done in accordance with San Joaquin county <br />ordinances, state laws, and rulesrand 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 <br />permit is issued, I shall not employ. any per-son-in..such•manner_as,to become subject to workman compensation laws of California." <br />Contractor's hiringror sub -contracting si-gnature.certi'fies.the following: "I certify that in the performance of the work for which <br />this permit is issuet,J, shall—employypersons -subject t workman's` compensation laws of California." <br />The applicant m cll or all requi ed`in� Complete drawing on reverse side. <br />Signed X Title: Date: <br />xFOR--DEPARTMENT'USE ONLY <br />Application Accepted by <1 A ea Q Stk 466-6781 <br />Additional Comments:R Lodin .369,3621• <br />Pit or Grout Inspection by '' 0 Manteca'823-7104 <br />Final Inspection by Date e .L Tracy`+_.835-63851 <br />Applicant - Return all copies to:. Ln vironmental Health Permit/Services 1601 E. Haze lton 'Ave , P.0. Box 2009, Stk., CA 95201 <br />LH 13-24 <br />14-26 <br />REV. 10/82 <br />10/82 500 <br />.A <br />F, <br />