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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> J 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 - <br /> PERMIT EXPIRES I•YEAR FROM DATE ISSUED <br /> FILE C <br /> Y� (Complete in Triplicate) <br /> Application is hereby made to the San •oaqui.nlLocal Health District for a permit to construct and/or instaif the work herein described. This application is <br /> made in con6plianteyV'Vifh 5aA JpaquiiU G$LntY;drdinance&.,549-forsewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local iealth`District.. ; t _ �� <br /> +Ir-�,i <br /> R <br /> Job AddressY _�y( :: G Sf'y. 4; City Lot Size PM �J <br /> Owner's Name - . Address Phone °Is <br /> I � <br /> Contractor H Address License No. _Phan _ <br /> TYPE OF WELL/PUMP: NEW.WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK i SEWER LINES DISPOSAL FLO. PROP. LINE <br /> �..... __ .. <br /> FOUNDATION <br /> AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE-OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATlONSr <br /> ❑industrial ❑ Open Bottom' ❑ Manteca Dia. of Well Excavation— 1° Dia. of Well Casing. u <br /> ❑ Domestic/Private Gravel Paok <br /> �( i.7 Tracy Type of CasingPVCf S ifications <br /> r'X Public ❑ Other i 171 Delta Depth of Grout Seal I Arl t of Grout <br /> I i Irrigation —Apprax. Depth) ( 1 Eastern Surface Seal Installed by dr_11-1-@-r <br /> Repair Work Done ❑ Type of Pu' <br /> i p --�L— H.P. State Work pone <br /> Well Destruction 0 Well Diameter Sealing Material{top 50') <br /> Depth-- I Filler Material(Below 501) w <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION l l REPAIR/ADDITION I I DESTRUCTION I I INo septic syslor e r e � pu i war is <br /> available within 20p0 feet.) <br /> Installation will serve: Residence!E Commercial_ Other h'k�� 2 ;� Ig�� <br /> Number of living units: Numtter of bedrooms I U r <br /> Character of soil to a depth of 3 feet:I—�� <br /> Wale <br /> SEPTIC TANK Q Type/Mfg I� <br /> PKG. TREATMENT PLT. ❑ Capacity No. CompaftMT <br /> Method of Disposal <br /> Distance t ne8ret: Well Foundation Props <br /> LEACHING LINE Ll No, & Length of lines Tot�Ilngth/1�1� <br /> FILTER BED ❑ Distance t0 nears : Well Foundaliort P,__trty Li <br /> SEEPAGE PITS t I Depth I Size Number <br /> SUMPS Ll Distance tri nearest: Well Foundation property ' LTH I <br /> DISPOSAL PONDS ❑ N� CEE <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 certillies the following:"i certify that in the performance of the work for which this permit Is issued, I shall not <br /> I employ any person in such mannor as to become-subject to workman's compensation laws of Caliiomis."Contractor's hiring or sub-contracting signature <br /> i certifiis 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 /> I .tion laws of California,- ; <br /> The applicant must Gaff for pll required inspeclioris. p ted wing on res rse side. r <br /> Signed 1 � ( • <br /> Data: <br /> 4— <br /> FOR ARTM USE ONLY <br /> Application Accepted by F'XDate -+a f "� V • Area • ' <br /> Pit or Grout inspection by Date Final Inspection by pie >f <br /> Additional Comments: <br /> ❑ Stk 466.6781 ❑ Lodi 3693621 ❑ Manteca 823-7104 17 Tracy 835-6385 <br /> II. Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazehon Ave., P.O. Box 2D09,S1k., CA 95201 <br /> rI r g <br />� r d <br /> FEE AMOUNT DUEND, <br /> APu OUNT REMITTED K RECEIVED BY DATE PERMIT' <br /> INFO <br /> •.EM13.24(REV.Ito 51 <br />