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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT. EXPIRES 1 YEAR FROM DATE ISSUED' <br /> (Complete in Triplicate) - <br /> r <br /> `a permit to construct and/or install the work herein described. This application is <br /> Application is hereby made to the San Joaquin Local Health District for <br /> e or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for sewag <br /> Local Health District- /� I <br /> �L r� Ik&� �/� Q7City� -`Lot Size— PM _ <br /> Job Address y. ...` r ; , N" :,.!". <br /> Q 1 ? J _ Address 1�4�0 .��sN1�Q' �0 Phone — — <br /> Owner's Name _ ,r�-L- 1i 21,�p '3 —-- <br /> Punrar�oeDrlltersOrlll �Q_ 43 �c� - _License No. <br /> lPhone P11-3 <br /> Contractor _ kg�lMdress <br /> TYPE OF WELL/PUMP: NEW WELL )C WELL REPLACEMENT G DESTRUCTION C <br /> PUMP INSTALLATION- SYSTEM REPAIR l OTHER L <br /> DISPOSAL FLD.. _ PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK �jJl�' — SEWER LINES `;. � PITS/SUMPS <br /> FOUNDATION AGRICUL-T-URE WELL' - OTHER WELL ` <br /> INTENDED USE TYPE OF WELL rPROBLEM AREA CONSTRUCTION�SPECIFICATIONS p r� <br /> Industrial O n Bottom C Manteca Dia. of Well Excavation_�I _ Dia. of Well Casing <br /> CI C <br /> pe <br /> teL Specifications <br /> ZDoiestic/Private C Gravel Pack C Tracy Type of Casing~ S <br /> - ¢ <br /> Depth of Grout Seal �� -- Type of GroutliA-J <br /> G Public O Other ❑ Delta G� <br /> 4d Irrigation _-Approx. Depth' L Eastern Surface Seal Installed by - <br /> Repair Work Done C Type of Pump — H.p. _ State Work Done <br /> Ii <br /> Well Destruction Li Well Diameter _ Sealing Material (top 501 <br /> If Depth_ <br /> Filler Material (Below 50') <br /> E OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Cl DESTRUCTION -1 (Noavailable <br /> septic system permitted if public sewer is <br /> TYP <br /> ,. available within 200 fest. <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 /> _ Capacity 1 No. Compartments <br /> SEPTIC TANK G Type/Mfg <br /> Pr Method of Disposal <br /> KG. TREATMENT PLT. <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ] No. & Length of lines Total length/size.— <br /> FILTER BED F_ Distance to nearest: Well _. _ Foundation—._ Property Line <br /> SEEPAGE PITS 17 Depth Size Number <br /> 1 <br /> Prop <br /> SUMPS ( , Distance to nearest: Well Foundation Property Line w <br /> -9r . -_ L <br /> DISPOSAL PONDS -1 ' -.. <br /> rk will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and that the wo <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." Contractors 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 applicarvust,call fo at a red inspections. Complete drawing on reverse side. + <br /> — <br /> Title: ire r nl -- Date: J- <br /> Signed <br /> 4 !- FOR DEPARTMENT USE ONLY <br /> �'T�L � <br />