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1 APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA �Ul'T;Q o <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED J, E P 187 <br /> (Complete In Triplicate) <br /> W: <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work here01q%"tyM f'Off Mp1iKMTH <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and ITAgµlat{gp�tgf <br /> Local Health District. wCli{Yt AIS <br /> Job Address `� / �`�— City ^ Lot Size PM <br /> Owner's Name ^ Address C­ it- Phone <br /> Contractor k_j Address fr A License No/`o .�_-�._.__Phone <br /> TYPE OF WELL/PUMP: NEW WELL 54, WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ,X SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK D SEWER LINES /��I _— DISPOSAL FLO. — PROP. LINE <br /> FOUNDATION LC1 AGRICULTURE WELL OTHER WELL--n— PITS/SUMPS ( (� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <2 Dia. of Well Casing <br /> Domestic/Private 5(Gravel Pack ❑ Tracy Type of Casing_ ti Specifications <br /> i 1 Public Ll Other F1 Delta Depth of Grout Seal ~'d Type of Grout <br /> I Irrigation ~ _..Approx. Depth ~ I 1 Eastern Surface Seal Installed by � R <br /> Repair Work Done Li� Type of Pump H.P. l Stare Work Done <br /> Well Destruction CI Well Diameter Sealing Material (top 50') <br /> Depth y Filler.Material (Below 50') <br />{ TYPE OF SEPTIC WORK: NEW INSTALLAT.iON I 1 REPAIR/ADDITION 1-1 DESTRUCTION I l {No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial`/ Other " <br /> Number of living units: Number of bedrooms <br /> 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 PITS I 1 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: "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." i <br /> The applicant sl call for all required inspections. Complete drawing on verse side. I <br /> Signed X -Title: Date: / 3 <br /> C FOR DEPARTMENT USE ONLY i <br /> f[ D <br /> d Application Accepted by 4 Date Area <br /> Pit Grout I pection b f Date / Final Inspection byJZr7lrt Date <br /> f <br />! Additional Comments: ronwIr <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 O Manteca 6920104 ❑ acy 835-6385 I <br /> Applicant- Return all copies to: Environmental Health Permit/Services 160 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> + EH 1324)REV,t i H 5) ��� tpo L �J�{ <br />` EH 14-26 l LL V <br /> 1 <br />