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I <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT y. <br /> `j 1601 E. HAZELTON AVE., STOCKTON, CA <br /> —Telephone (203) 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 OFdinance.No.549 for sewage or No. 1862for well/pump and the Rules and Regulations of the San Joaquin. <br /> Local Health District. ,C _ <br /> b`Addres City <br /> JoLot Size PM <br /> - Owner's Name AddressPhone - <br /> ",s/H s %` <br /> n <br /> Cont acty- 4 GC' ce Address IDM� �V'-X 7&7 w"." License NoZ��& Phone <br /> TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT ❑` DESTRUCTION ❑ <br /> k --? PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER G ' <br /> r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> 4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial C Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private Gravel Pack C Tracy Type of Casing _ Specifications <br /> ❑ Public 00 ther O Delta Depth of Grout Seal __ Type of Grout <br /> ❑ irrigation ---L-Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Q <br /> Repair Work Done C Type of Pump H.lP.- State Work Done , <br /> V <br /> Well Destruction ❑ Well Diameter __._ Sealing Material (top 50} - v <br /> Depth_._ Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ EPAIR ADDITION a DESTRUCTION ❑ (Na septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Re;i2ence Y Commercial` Other <br /> Number of living units: V .a <br /> Number o Broom <br /> 43 <br /> Character of soil to a depth of 3 feet: __ Water table depth G' <br /> SEPTIC TANK x Type/Mfg r Capacity No. Compartments — <br /> PKG. TREATMENT PLT.0, D Method of Disposal <br /> ,y y n, ' <br /> i Distance to nearest: &Well Foundation Property Line <br /> 1 . LEACHING LINE No. & Length of;lines / " � '�^ Total length/size— <br /> FILTER <br /> ength/sizeFILTER BED ❑ Distance to nearest: Well+_ Foundation /�r Property Line_4:-- <br /> SEEPAGE PITS e Depth J Size Number <br /> SUMPS ❑ Distance to nearest: Well 100e, foundation_A2 Line — <br /> 1 DISPOSAL PONDS ❑ �• — — <br /> I hereby certify that I have prepared this application and that the work vw11 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 /> empty any person in such manner as to become subiact to workman's compensation laws of Cal"tfomia."Contractor's hiring or sub-contracting signature <br /> certifies the following::'I certify that_in the.performance of the work for which this permit is issued.J.shall.employ_pe=ns sub}ect.to workman's.compensa- <br /> tion laws of California." <br /> The applicant mu cell for all uir inspections. Complete drawing reverse- e. .,y:i�: <br />