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APPLICATIONS FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES-1 YEAR FROM DATE ISSUED <br /> i F <br /> (Complete in Triplicate) <br /> F ` 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. 54 for se go or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address L�'Va , 1 fter-t L Cit PM <br /> Y Lot Size��•t,C'lLf�.tx� <br /> .O'VA&'Adnam = - ` l Address <br /> f 1 Phone <br /> Contraclof1-_ ,4�� 1 Address . &X <br /> License No. �7 z Z phone <br /> TYPE OF WELL/PUMP .c, "� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Lli <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 /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack El Tracy Type of.Casing Specifications <br /> ( I Public F1 Other I1 Delta- � . .Depth oGrout Seal Type of Grout <br /> I t Irrigation <br /> ation 6^ <br /> 9 lu,.- "Approx, Depth I I E'ast�errn Surface Seal-Installed by <br /> Repair Work pane D� Type of Pump . HP. 1_x <br /> State Work pone _ <br /> Well Destruction LiWell-Diameter Sealing`Material Ito�p 50'l . <br /> Depth Material MeloVW') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I AIR/ADDITION I. DESTRUCTION I I (No septic.system permitted if public sewer is <br /> i � available_within 200 feet.) <br /> Installation will serve: Residence Commercial— Other <br /> f <br /> Number of living units: go Number of rooms��---- a \ <br /> Character of soil to a depth of 3 feet: 'L.� <br /> Water table depth `f`� <br /> SEPTIC TANK ❑ Type/Mfg Capacity �No. Compartments'" <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> 3 Distance t nearest' ' Well Foundation Property_Line <br /> LEACHING LINE ❑ No. & Length of <br /> I nes <br /> Total length/iize <br /> FILTER BED ❑ Distance to nearest:\ Well Foundation Prope!Iy Line <br /> SEEPAGE PITSDepth,," _ •Size.. Number <br /> i SUMPS Ll Distanct} to nearest: Well r .___ property Line- <br /> DISPOSAL '�— <br /> t �� Foundation �: <br /> PONDS ❑ n <br /> I hereby certify that I have prepared,this appl6tion 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 4balth District. , <br /> t Home owner a or licensed agent's signature•certifies the following: "1 ceitify-thapi the performance of the work for which this permit is issued, I shall not <br /> employ y y person in such manner as to become subject,to•workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> 1 ioncertifies!laws of Cthe lalifor in •,i certify that in the Performance .the work fiir which his permit is issued, I shall employ persons subject to workman's compensa- <br /> I The applicant calf for all r u ed ' spections,.Complete drawing n reverse side <br /> Signed X Title: <br /> Date:E7��1,1� <br /> i <br /> FOR DEPARTMENT USE,'ONLY <br /> i <br /> Application Accepted by <br /> _ Date Area 12 <br /> Pit Grout_Inspection by <br /> elt� , Date �9�` Final Inspection by <br /> Date <br /> Additional Comments: ► <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ' <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E.-Hazelton Av`e :P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT'NO. <br /> a EH 13-24IREV.1i851 <br />