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? as <br /> APPLICATION FOR 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 /> (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 forwage r No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> „��yy � <br /> Job AddresslTS o) V C�j N�D��['Q1� � JD city Lot Size � p� <br /> Owner's Name Address Phone <br /> Contractor 'a � /►'S/ AddressLicense No <br /> 14 , —Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 71 DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> 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 Excavation <br /> Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing S <br /> 11 Public ❑ OthSpecifications <br /> ❑ Delta Depth of Grout Seal Type of Grout <br /> El Irrigation Other---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. <br /> State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION,^ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> Installation will serve: Residence 71 available within 200 feet.) <br /> _ Commercial Others <br /> Number of living units:ZVj&l Number of bedroom <br /> 4dl <br /> Character of soil to a d) hof 3 feet: <br /> SEPTIC TANK ��f9� Water table depth � <br /> ❑ Type/Mfg Capacity-4W h-'-� No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> / Method of Disposal <br /> Distance to nearest: Well Foundation Z— Property Line ,, <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BEDS y�I Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ Property Line <br /> 1 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:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed )L L�,''��,� ® Title: 0 v/f^'' 1'- (1 fes' "'_ <br /> Date: <br /> F D RTMENT USE ONLY <br /> Application Accepted by _ t Date <br /> 3 <br /> Area <br /> akid, <br /> Pit or Grout Inspection by a Final Inspection by <br /> �' Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED K <br /> INFO RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24(REV.1/e 5) <br /> EH 14-28 --7o, d O�b �'/c <br /> r� � C�'7- <br />