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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (249) 466-6781 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED 0 <br /> (Complete in Triplicate) <br /> AppGcation is hetaby 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 sew <br /> Local Health District'. age or Na.1862 for welUpump and the Rules and Regulations of the San Joaquin <br /> Job Address q 1✓ r 1 i1 - `ro X O <br /> 1 ��!�—�-�a�tJCity„ G� Lot Size PM <br /> Owner's Name =,f't o VA-t'1�' L /v r;�+ t fAddragg / 1 14140_ d�+Phana — `✓ a <br /> Contractor License No. Phone <br /> TYPE OF ELLIPUMP: NEW WELL ❑ WELL REPLACEMENT U DESTRUCTION 0 <br /> PUMP INSTALLATION ❑. SYSTEM REPAIR 0 OTHER 0 <br /> DISTANCE TO NEAR SEPTIC TANK SEWER LINES DISPOSAL FLO. <br /> PAft <br /> DATION AGRICULTURE HER WELL PITSISU.MPS _ <br /> tN7ENDED USE TYPE Of L AREA CONSTRUCTION SPECIFICATIONS <br /> O irxlustriay ottom Manteca Dia. of Well Excavation <br /> r Dia.of Well Casing <br /> C7 Domestic e ❑Gravel Pack 0 Type of Casing S <br /> 1'1 Pu pecitications <br /> El Other n Delta Depth of Grout Seat Type of Grout <br /> 3 I Irrtyation Approx. Depth I I Eastern Seal Installed by <br /> _ t f <br /> Repair Work Done U Type.of Pumpr+*ate Wolk Done <br /> W01 Destruction 7 Well Oiarneter Sealing Material (tap 50') <br /> Depth Filler.Material(Bela ,.So,) <br /> j <br /> TYPE OF SEPTIC WORK;; NEW INSTALLATION I 1 REPAIR/ 051110N DESTRUCTION I I (No septic system permitted it public sewer is <br /> available;within 200 feet.! <br /> 1 Installation will serve, Residence.— Commercial— Other <br /> Number of fivirtg units:_ Numlxer Of bedrooms <br /> Character of sail to a depth of 3 feet: <br /> SEPTIC TANK Water table depth <br /> O Type/Mfg Capacity U U No. Compartments <br /> PKG. TREATMENT PLT. <br /> r e Method of Disposal <br /> Distdnca to'nearest Well _ Foundation 12V, Pro' <br /> petty Line. <br /> LF-ACHING LINE L"t No. &Length of tutee {) <br /> Total lengthlsire <br /> FILTER BED Cf Distance to neafesr WeN _� ~ <br /> I FoundatioJt �aj,L Property Line�r <br /> t SEEPAGE PITS t t Depth S"rrrt <br /> SUMPS - Number <br /> I,t Distance to nearest; Well Foundation <br /> DISPOSAL PONDS 0 — Property Line <br /> j Ihereby cattily that 1 have <br /> i prepared this application and that the work will be done in accordance with San Joaquin county ordinances, <br /> rules and regulations of ttie San Joaquin Local Health District. state laws, and <br /> Norse 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$Rall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California,"Contractor's hiring or sub contracting signature <br /> certifies the following:olifni "1 certify that in the performance o!the work for'which this permit is issued,,f$hall employ persons subject to workman's compensa- <br /> tion laws of.C.atifornia." <br /> The applicant must call or all required inspections. Complete drawing on reverse side. <br /> Signed <br /> I ;t1a: ✓i, .f,- Date: _ ._ <br /> FOR DEPA irmEmT tfSE OwL1f <br /> Application Accepted by p= <br /> Date✓" r� Area <br /> Pit or Grout Inspect ,. Date <br /> Final inspection by Date <br /> Add:tionai Comments' <br /> 0 Stk 466-6761 ❑ Lodi 369-3MV O Manteca an-7104. ❑Tracyt <br /> 835-6385 <br /> Applicant• Return an copies tp: Envitorvnental Health P&Mdt1S6MC" 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i <br /> j MOUNT DUE AMpUtl7'REkifTTED QK H AEtE1VEp 8Y t]hTE <br /> PEttMfT'lil0. <br /> l0 <br /> st#H t3"2{tttkY�it x a3 TNNJ <br />