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- _ x <br /> a 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 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 /> f <br /> made in compliance with San Joaquin County Ordinance No.549 sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. n � <br /> Job Address DBS `r City �a�C/� Lot Size Zr ��— PM <br /> 4 Owner's Name 9LIZV, h74&2 Address SS206a- Phone C16 <br /> Contractor's Name' AK License Np: b j` Phone <br /> 1 <br /> TYPE OF WELL/PUMP: – <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑'"` <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 11OTHER (7) <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> li FOUNDATION AGRICULTURE WELL OTHER-WELL PITS/SUMPS <br /> INTENDED USE �e TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS } <br /> ❑ Industrial I ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> %{ El <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specific' <br /> ations <br /> E ❑ Public ❑ Other LlDelta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material Below 501 <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION.E] (No septic system permitted if public sewer is <br /> k available within 200 feet.) <br /> F Installation will serve: Residence— CommercialOther <br /> Number of living units: Number of bedrooms <br /> S <br /> i Character of soil to a depth of 3 feet: Water table depth <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 PITSI❑ Depth Size Number <br /> SUMPS) !!!❑ 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: "l certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> t!onlifornia." <br /> The!on -!p 'cant ust for al it ins S. Complete drawing ors`reverse side. <br /> i z <br /> Signed Tlkle. Date: I <br /> I! t <br /> ii FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date %Z ��� Area <br /> Ph or Grout Inspection by Date Final Inspection by Date = <br /> s <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 - ❑ Tracy 8355-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> I: <br /> FEEK <br /> *.. <br /> INFO AMOUNT DUE AMOUNT REMITTED. CASH RECEIVED BY DATE PERMIT'NO. <br /> +EH 1324(REV,10/631 � l <br /> L EH 1426 '� �+ <br />