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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL—ION AVE., STOCKTON, CA <br /> Telephone (269) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> applicationscribed. This <br /> Application ns Nance withdSano t.he Sn Joaquin Local Health District for a Joaquan County Ordinance No.549 for sewage or permit <br /> No. 1862 for well apump and the Rules and/or install the work IR gulations of he SanJoaquin <br /> made in p <br /> Local Health District. <br /> City Lot Size��c"`^'�""`J PM <br /> Job Address <br /> 7 Address Phone <br /> Owner's Name <br /> Contracto <br /> g `I Address SGG�►— ,� 6"�' - License No. -VZ 7 Phane I �� <br /> TYPE OF WELLIPUMP: � NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LJ <br /> PUP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Wen Casing i w <br /> ❑ Industrial ❑,Open Bottom El Manteca Dia. of Well Excavation �f <br /> T e of Casin Specifications <br />` ❑ Domestic I Private ❑Gravel Pack ❑ Tracy yp g Type of Grout <br /> t`1 Public ❑,Other 171Delta Depth of Grout Seal <br /> I I Irrigation ,Approx. Depth l I Eastern Surface Seal Installed by i <br /> 0H p State Work Done —_ <br /> Repair Work Done ❑ Type of Pump f x <br /> Well Destruction ❑- Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') <br /> fTYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l 1 DESTRUCTION l I INo availabpe1wthirt=20c system 0 f eer rtjed if publ slwer'is <br /> Installation wild errve: Residence !�Commercial— Other <br /> GNumber of living units: Number of be s Water table dept <br /> Character <br /> Character of soil to a depth of 3 feet: , <br /> Type/ Capaci y No.tCompartments <br /> SEPTIC TANK 9 <br /> r Mathod"of Dispgsal , <br /> PKG. TREATMENT PLT. ❑ <br /> ,? Distance to nearest: <br /> Well Foundation-��_ Property Li a_ _z <br /> r <br /> � 4O? Total length/size. ' <br /> 0x <br /> LEACHING LINE,- / `iNo. & Length of lines �„ , t + •. 3 _ , <br /> FILTER BED ❑'' Distance to nearest: Well —. Foundation� - Property"Lino <br /> v <br /> SEEPAGE PITS' l I'; Depth Size � <br /> SUMPS f Ll, Distance to nearest: Well Foundation <br /> Property Line <br /> DISPOSAL-PONDS ❑ 1 <br /> thereby certify that l 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 certhat in the per#ormance of the work for which this permit is traced, k shall not <br /> tify <br /> employ any person in such t6nner as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature <br /> certifies the fallowing: "I ceRify..that.in..the performance-of.the work for.which this permit.is issued, I shall employ-personssubjact to workman's.compensa <br /> tion laws of California." �, <br /> The applicant mu calk iorlp qui d inspections: Complete-drawing on reve�s side:- �( <br /> _ - - <br /> l <br /> V, Date: Oct T0 0 <br /> Signed X Title: <br /> r FOR DEPARTMENT USE ONLY / f <br /> - Date/�'� Area y <br /> Application Accepted by .l - <br /> Pit or Grout Inspection bye I Date Final Inspection Date <br /> by <br /> � <br /> i ' <br /> Additional Comments: <br /> ❑ Stk 466-6781 El. 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, 5tk., CA 95201 <br /> `i CK RECEIVED BY DATE PERMIT�NO. <br /> ff%�'MOUN:T'DU9EAMOUNT REMITTED CASH <br /> EH 1324(REV.r i H sY ' �� $g— �EH 14-25 <br />