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' APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> I I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I <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.548 for sewage of No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District.'I' <br /> Job Address .� City Lot Size PM <br /> IIS I �i <br /> Owner's Nam h? Address/ 1 Phone I' "d � { <br /> f <br /> Contractor I f LCj Address License f+io, !` �f <br /> G2 3 Phone <br /> ,TYPE OF WELL/PUMP;. NEW,WELL;j WELL REPLACEMENT ❑ DESTRUCTION ❑ j <br /> { I�; PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST:-SEPTIC TANk— SEWER LINES ZW! DISPOSAL`FLD `�.PROP. LINE B� <br /> FOUNDATION — AGRICULTURE WELL"?kafP__OTHER-WELL' _e,PITS/SUMPS._ " <br /> INTENDED USE TYPE OF WELL PROBLEM AREA �, CONSTRUCTION SPECIFICATIONS %' I <br /> ❑ 16dustria! ys' ❑ Open Bottom Manteca Dia. of Well Excavation If Dia. of Well Casino <br /> f .f. _ <br /> X-Domestic/Private Gravel Pack ❑ Tracy Type of Cas+ng � ` Specifications (�� /46P,f <br /> f Public' yI Cl Other ❑ Delta Depth of Grout Seal __. Type of Grour � / F <br /> - I I Irrigations 'I. _Approx. Depth 11 Eastern Surface Seal installed by <br /> Repair Work Done L7 Type of Pump r H.P. State Work Done �I. <br /> Well.Destruction U Well Diameter tSealing Material (top 501 <br /> Depth Filler Material l8elow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION LI DESTRUCTION I I (No septic system permitted if public sewer is!! <br /> available within 200 feet.) <br /> Installation will serve:' Residence_t Commercial_ Other_ r` <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth f <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments !' i <br /> PKG. TREATMENT PET. ❑ Method of Disposal ` <br /> Distance to nearest: Well Foundation Property Line \ <br /> f r'. , I yR <br /> LEACHING LINE I ❑ No. & Length of lines Total length/size <br /> A <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> I "! <br /> SEEPAGE PITS ; %I 1 -Depth Size -0: • { > = _ Number <br /> SUMPS Ll,a=;Distance to nearest: \,Well Foundation Property Line i1 <br /> DISPOSAL PONDS ❑ �# �' �` - <br /> I hereby certify that I Have prepared-this application and that the work will be done in accordance With'San Joaquin county ordinances, state laws,rand <br /> rules and regulations of the.San?Joaquin'Local Health District. ,; , .i <br /> Home owner'r 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�.n such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature r <br /> certifies the following: 11-certify that in the performance of the.wotk for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of-California.,' `ti <br /> The applicantust'ca for all re ed ' spections: Complete drawing on reverses e. it <br /> Signed X _ Title: G- �p�.�� t <br /> Dale: <br /> IFOR DEPARTMENT USE ONLY l I <br /> Application Accepted by Date Area <br /> Pito Grout Inspection by 7Final Inspection by <br /> t <br /> Additional Comments:' <br /> ❑=Sik 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health,Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE <br /> i <br /> q_ I. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> ♦ EH13-24(REV:1iK5) +�'� �'• (�� --- -Q� <br /> EH 14-28 <br />