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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 r <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> mplete in Triplicate) <br />€ � � . ji Application is hereby made to the San Jn 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.5479 forsewageor No. 1862 for well/pump and the Ru and Regulations <br /> �f theJoaquin <br /> Local Health District. �j7r}G.i�'7� 5ST77- <br /> f PD J� Lot Size PM <br /> City <br /> I Job Address <br /> f <br /> /tPN 2,59 F OZ`-D3 C��C g Phone ]�Z <br /> �yz1 <br /> wr-� DUL� �=i4L7�'y Address <br /> Owner's Name P�� ' <br /> yo m,o-vY <br /> Contractor. � <br /> 2ay�ress ��� � /1�`fJ¢'T��License Mo.��/Z-ZA�-Phone��8-13� <br /> r TYPE OF WELL/PUMP: NEW WELL E1WELL REPLACEMENT ❑ DESTRUCTION ❑{ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERTSr � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ��� <br /> PROP. LINE ��9 <br /> .' FOUNDATION <br /> AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> M <br /> INTENDED USE TYPE OF WELL <br /> PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of�el�i� <br /> Ll Industrial ❑ Open Bottom (I Manteca Dia. of Wel! Excavation <br /> Type of Casing Specifications <br /> F] Domestic/Private ❑ Gravel Pack L3 Tracy YP Type of Grout - <br /> f 1 Public F1 Other d 1-1 Delta Depth of Grout Seal k <br /> i I I Irrigation --Approx. Depth l 1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump <br /> H P State Work Dane <br /> Sealing Material (top 50'1 <br /> Well Destruction ❑ Well Diameter — <br /> Depth � Filler Material (Below 50'1 <br /> k TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I availableseptic <br /> wi within 200 feetpermitted if public sewer is m" <br /> Installation will serve: Residence Commercial— Other 0 <br /> Number of living units: Number of bedrooms <br /> s Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK a Type/Mfg Capacity �A <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Property Line <br /> j Distance to nearest: Well Foundation <br /> I <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> FILTER BED EJ Distance to nearest: Well Foundation Property Line <br /> Size _ Number <br /> - SEEPAGE PITS I I Depth . <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line U <br /> I DISPOSAL PONDS ❑ <br /> i <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, an <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 /> employ any person in such manner as to become subject to workman's compensation laws of California." Contracersonsrrs irin ect toor -corkman1sgompeture <br /> signa <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,!shall employ p I <br /> tion laws of California." <br /> The applicant rust call for I required inspections. Complete drawing on reverse silo. D <br /> <c l.-S'T Date: <br /> Signed X Title: <br /> F <br /> FOEPARTMENT USE ONLY <br /> k Data r Area 2 <br /> Application Accepted by <br /> Pit or Grout Inspection by date <br /> Final Inspection by Date `a <br /> Additional Comments: <br /> 11 5tk 466-6781 © Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> th Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> Applicant - Return all copies to: Environmental Heal <br /> C RECEIVED BY DATE - PERMIT No. <br /> FEE <br /> AMOUNT DUE AMOUNT REMITTED ASH <br /> INFO <br /> I +.EH 13.24 1REV.t i n 51 e0 9 O—A\ <br /> 1 EH 14-26 <br />