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_ 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'ippl,­,tion is <br /> made <br /> Local in co pDiste 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 /> Job Address 3,f 6,IX ( .f i���is �i,l c ,�O�' ,r <br /> Lot Side PM <br /> Owner's Name Address Al &w .ST �Al.0 CA Phone 620q - <br /> CA) <br /> Contractor m�2 CY ulwr/oN Address License No. !/$OSot Phone - r <br /> TYPE OF WELL/PUMP: NEW WELL 04 WELL REPLACEMENT ❑ DESTRUCTION ❑ HlNfsoa/NO WELL <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> O Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ZQf 1 Dia. of Well Casing 2 go r 4" <br /> ❑ Domestic/Private (>A Gravel Pack ❑ Tracy Type of Casing PVG -Scl, 40 Specifications <br /> ❑ Public dagrvaugr ❑ Other ❑ Delta Depth of Grout Seal 2$ 2S Type of Grout <br /> ❑ Irrigation 1! al --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 501 <br /> Depth 60, Filler Material (Below 50') <br /> PE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation ' serve: Residence_ Commercial__ Other <br /> Number of living un Number of bedrooms <br /> Character of soil to a depth o t: er table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well undation Property Line <br /> LEACHING LINE ❑ No. & Length of 1'. Total length/size <br /> FILTER BED O Distance rest: Well Foundation rty Line <br /> SEEPAGE PITS Depth Size _ Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DI AL 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, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of Califomia." Contractor's hiring or subcontracting 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 mus all for all required i ctions. Complete drawing on reverse side. 41-11-f <br /> Signed X Title:�� � Date: .1'/ '/8 7 <br /> PA ONLY cy J <br /> Application Accepted by [� Date 3�'!` Area <br /> Pit or Grout Ins pe on CT_r D Q. �w ,. Date « S Final Inspection by �2G�.� Date <br /> Additional Com nta: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Servic ea 1601 E. Hazetton Ave., P.O. Box 2009, Stk., CA 95201 <br /> r <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. <br /> INFO <br /> . EH 13-24(REV.1/e 5) S, <br /> EH 14-25 ( GS — <br />