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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 'Y/v <br /> 1601 E. HAZELiON AVE., STOCKTON, CA /Q <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 application is <br /> made in compliance with San Joaquin County Ordinance No.549 for selvage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. // rte/ ^��/ '�—.,�7 <br /> Job Address �/+6 oCj �/,t-y�//Zz /� / % city��1 _ Lot Size) <br /> Owner's Name��Z � l� C ( I !`lddres i Phone <br /> f3 <br /> Contractor's Na cc°` license No. L' Z A / PhoneJ/ -. <br /> TYPE OF WELL/PUMP: NEW WELL f.. WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK zrLaA1V�_ rzWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION _ — AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS, / 6� <br /> ElIndustrial pen Bottom ❑ Manteca Dia. of Well Excavation'y_ Dia. of Well Casing Cv / <br /> L'- rmestic/Private 11 Gravel Pack ❑ Tracy Type of Casinga.�vi.z't_-P <br /> Specifications� 7 <br /> 171Public El Other ❑ Delta Depth of Grout Sea _ Type of Grout <br /> ❑ Irrigation ---Approx. DeptthJ�)'❑ EEpstern Surface Seal Installed IN <br /> Repair Work Done ❑ Type of Pump e�Z2- H.P. 1��. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 2DO feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of will to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ca <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 /> Q <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line . <br /> DISPOSAL PONDS ❑ <br /> 1 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 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 myspcalil UK all required inspections. Com t rawing on reverse side. <br /> Signed Xr, — - -- �.z - � rite: Date: l <br /> FOR DEPARTMENT USE ONLY / <br /> Application Accepted by Date <br /> Date!©��b <br /> Pit or Grout Inspection by Z. / Date 4 4zK Final Inspection by C Date <br /> Additional Comments: <br /> ❑ Stk 4665/81 ❑ Lodi 369-3621 ❑ Manteca 8237104 ❑Tracy 83546385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE —AMOUNT REMITTED CA 4 RECEIVED BY.-•� DATE PERMIYNO. <br /> INFO <br /> � �J-1-1H3S / <br /> 04;3-24(REV.10/e3) � • o o �� �"�b/�W b d <br /> EH tats <br />