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A- � <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> 1601 E. HAZELTON AVE., STOCKTON, CA n o - ?0 <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> uin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> Application is hereby made to the San Joaq <br /> or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage <br /> Local Health District. <br /> r l a W City Lot Size PM <br /> Job Address `�/� <br /> Owner'sName <br /> GC-N N Y • I r!! '{ Address 3 7Phone z0l 0 <br /> Address License No. Phone <br /> Contractor <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE , <br /> FOUNDATION AGRICULTURE WELL ! OTHER WELt PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> 1-1 Public <br /> Cl Other ❑ Delta Depth of Grout Seal Type of Grout <br /> _ W <br /> I I Irrigation ­Approx. Depth I i Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material stop 501 <br /> . Depth— Filler Material lBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADOITION I I DESTRUCTION availabetic system peithin rented if public sewer is <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 /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ R <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 /> SEEPAGE PITS I i Depth Size Number <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> ill 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 work w <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 /> j employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the fallowing: '9 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 must call for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: 0-y113 eiV Date: f� <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date I Area l <br /> Pit or Grout Inspection by Date <br /> Final Inspection by Date <br /> Additional Comments: <br /> 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant- Saturn all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED GASH ;:9:EC:EIVED BY DATE PERMIT NO- <br /> INFOEH 13-24 1REV.I/K 5) LSs f <br /> EH 14-26 <br />