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\� APPLICATION FOR PERMIT v <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTOU AVE.. STOCKTO4. CA PEIr1IT CO. <br /> Telephone (209) 466-6781 <br /> DATE ISS. L <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 tho work-horoin <br /> described. This application is made in compliance with San Joaquin County Ordinance He. 649 for semgo or M. 1862 f6r tall/pub <br /> and the Rulesnd R uons of the San qu 1 District. <br /> Job Address �a� lat� / °Subdivision Nna Ah7A— <br /> '' <br /> Owner's Name Address Phona <br /> Contractor's Name License No. Phono <br /> TYPE OF MEL PUMP WORK: NEN WELL WELL REPLACEMENT DESTRUCTION❑ <br /> PUMP INSTALLATIO(I ❑ SYSTEM REPAIR OTHER ❑ / <br /> DISTANCE TO NEAREST: SEPTIC TANK T' SEWER LINES DISPOSAL FLD. PROP. LINE_ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUXPS^4187,_ --C <br /> INTEt(TSE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,y <br /> D Industrial [:]Open Bottom ❑Manteca Dia. of Well Excavation <br /> Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing n <br /> Public []Other ❑Delta Type of Casing .\ <br /> U Irrigation Approx. ❑Eastern Specifications <br /> D Cathodic Protection Depth <br /> r, � Depth of Grout Seal <br /> CJ Geophysical <br /> L]Other Typo of Grout <br /> Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Mork Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADOITION LJ­ (No septic tank or seepage pit pemitted if public sewer is <br /> available within 200 feet.) N <br /> Installation will serve: Residence Commercial _ Other <br /> Nu=ber of living units: Number of bedrooms Lot size �►, r n <br /> Character of soil to a depth of 3 feet: Water table depth v l <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartem is <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. b Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size s Number ... <br /> SUMPS l—1 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 <br /> ordinances. state laws, and 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 <br /> permit is issued. I shall not employ any person in such manner as to become subject to workman�compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this permit is issued. shall employ persons subject to workman's compensation laws of California." <br /> The applicant s al for a required Inspections. Complete drawing on reverse side. `� <br /> Signed X r Title: Date:/ 7 <br /> P <br /> Application Accepted by '0 EENT USE ONLY Are# ❑ Stk 466-6781 <br /> Additional Comments: ❑ Lodi 369-3621 <br /> PitGrout Inspection by VW Dat Manteca 823-7104 <br /> Final Inspec on y Date Tracy 835-6385 <br /> --!pp1Acant- Raturn-al-l-copies to: Environmental Health-Permit/Services 1601 E. Hazelton Ave.. P.O. Box-2009,-Stk_,-CA--95201 <br /> FEE ASEUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO !� <br />