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y. Y <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 i 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'th <br /> 6 work herein described. This application-is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. . , <br /> h 9 <br />'I Job Address ' City Lot Size / PM <br /> ¢; <br /> e <br /> Owner's Name . � S -f 172C71) <br /> Address PhonI <br /> Contractor's Name & Licens No. Q•2 9 �3`� - Phone. 4 <br /> TYPE OF WELL/PUMP: ��" NEW WELL ❑ WELL REPLACEMENT ❑-` DESTRUCTiON ❑ _< <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ - <br /> DISTANCE TO NEAREST: SEPTIC TANK _SEWERrLINISP-OSALFLD. PROS Ll1VE <br /> FOUNDATION AGRICULTURE WEL OTHER WELL PITS/SUMPS <br /> - - - {"� <br />` INTENDED USE ' TYPE OF WELL PROBLE EA STRUCTION SPECIFiCATIONS � <br /> ❑ Industrial . ^�. ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> .-niu <br /> ❑ Domestic/Pnvate- `E-Gravel Pack ❑ T, Ty f Casing I _�� Specifications <br /> ❑ Public ❑ Other Delta Depth o ut Seal Type of Grout <br /> ❑ Irrigation �Approx. th ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑, Typeof-Pump H.P. State Work Done r1 <br /> Well Destruction` ❑ 'Well-Diameter Sealing Materia! (top 50') <br /> l <br /> ��•,-. };� y Depth Filler Material Below 50'} <br /> TYPE1OF.SEPTIC.WORK: ^NEW INSTALLATION ❑ REPAIR-/ADDITIO DESTRUCTION ❑ (Nwseptic'system permitted if public sewer is <br /> available within 200 feet.) <br /> - <br /> Installation will serve:.1-tiesidelnce Commercial— Othe 4 <br /> r <br /> f Number of living units:�� Number of bedrooms <br /> ECharacter of soil to a depth of 3-feet: `} # '�-� l Water table depth <br /> SEPTIC TANK f ❑ Type/Mfg Capacity yNo. Compartments <br /> 4 PKG. TREATMENT PLT. El j, pU51 Method of Disposal <br /> r Distances}to nearest: gWell Foundation= Property Line , <br /> LEACHING LINENo. &,Le-ngfh of lines Total length/size v <br /> l >, FILTER BED ❑ Distance to nearest: Well' Found <br /> Iti.11j Property Line=-. <br /> I SEEPAGE PITS ❑ Depth ( Number <br /> SUMPS ❑ Distance to nearest: Wali>- -W-Foun `� � Property Lirie� <br /> DISPOSAL PONOS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sar..Joaquin county ordinances, state laws, and <br /> i rules and regulations of the Sand Joaquin'Local-Health District .� <br /> Home owner�or..`licensed.agent'ssignature certifies the following: I certify that in the performance of the work for whrcli this permit'is issued, I shall not <br /> employ any person in'suc manner as to become subject to workman's compensation laws of California."Contractors hiring or sub contracting signature r <br /> certifies the following:"I itify that in_ the,perforrhance of the work for which this permit is issued, I shall-ernpersons subject to workman's compensa- <br /> tion laws of California.' <br /> The applicant must I or all re red in pe ions. Complete drawing on reverse side. , <br /> 1Ih Title: Date: <br /> Signed <br />'s FOR DEPARTMENT USE ONLY 1 <br /> 9d 6 <br /> Application Accepted by Date Area <br /> ` Pit or Grout:lnspection by I�. Date Final Inspection by f Z� Data <br /> Additional Comments: l — <br /> �❑ Stk 466-6781 ❑ Lodif 369-3621 anteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant R6tum all copies to: Environmental Hea h,Parmit/Services 1601 E. Hazelton Ave.; P.O. Box 2009{Stk., CA 95201 <br /> AMOUiVT M <br /> ° ,DUE ;AMOUNT REMITTED CK RECEIVED BY DATE PERMIY'NO. <br /> -r; :INFO <br /> CASH d <br /> +EH 13-24(REV 1x183 <br /> EH 14-26 <br />