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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 /> 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 Ordinpn�"',­ <br /> No. r sewage or No. 1862 for well/pumpand the Rules and Regulations of the San Joaquin <br /> Local Health District. Jy <br /> Job Addres�'� � '"`•"`� Cit <br /> Lot Size 4 PM <br /> �f W. �a Qe ' <br /> C <br /> " Address 3 _ Phone <br /> Owner's Name r4 / <br /> (� Q <br /> Contract + Address 00,0- AH L�?� , License No.L Phonec�7 D �� <br /> TYPE OF WELL/PUMP: NEW WELL ❑- WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE,OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ' <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy +�` Type of Casing Specifications <br /> FI Public ❑ Other f-1 Delta Depth of Grout Seal Type of Grout — <br /> I I Irrigation _.Approx. Depth I i Eastern Surface Seal installed by - <br /> Repair Work Done ❑ Type of Pump H•P <br /> State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler.Material (Below 50') <br /> TYPE_ OF SEPTIC WORK: NEW INSTALLATION 7,F1EPAIR/ADDITION l I DESTRUCTION [ I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> + <br /> Installation will serve: Residence Commercial_ Other. ` <br /> Number of living units: / Number of d om O t <br /> Character of soil to a depth of 3 feet: Water table depth /1 <br /> SEPTIC TANK >r Type/Mfg J Capacityf/nom No. Compartments 11 <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well �•J.( — Foundation. Property Line S <br /> LEACHING LINE No. & Length of lines 0. Total length/size <br /> FILTER BED ❑ Distance to nearest: Well �sD Foundation �6 Property Line __ — <br /> �7 <br /> SEEPAGE PITS Depth C 5 Size S _ Number <br /> SUMPS L! Distance to nearest: Well 'Foundation—AQ/ Property Line ...— <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared this application and that the work will-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 /> 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: "I 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 call far I r ui inspections. Complete drawing on reverse side. <br /> Signed X Title: �• Date: 'I <br /> Fr R DEPARTMENT USE ONLY <br /> ` Date Area <br /> Application Acc ed by �� <br /> Grout inspection tiy' D" ateFinal inspection by /l/11 /s' Dated <br /> Additional Comments: <br /> ❑ Stk 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 95201 <br /> FEEAMOUNT DUE AMOUNT REMITTED CK 0 CASH RECEIVED BY DATE PERMIT'NO, <br /> INFO <br /> +.EH 13-241REV.tiKri <br /> EH 14.26 lll//l 74( <br />