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APPLICATION FOR PERMIT <br /> SAN JOAQUIN.LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 468-6781 <br /> PERMIT EXPIRES 'I YEAR FROM DATE ISSUED <br /> j, (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 /> dr No. 1862 for welllpump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage <br /> Local Health District. 1�� CC <br /> Job Address <br /> '� ! 1 � /OGC7(° .J GeL- City C Ctb Lot Size li Cj2+' PM <br /> � S `1 �f <br /> s Address , .��r �� Az_ Phone <br /> Owner's Name <br /> ' License No.a55- - hone g <br /> Contractor �� .r �� Address f—� <br /> --- TYPE OF WELL/PUMP: 'NEW WELL WELL REPLACEMENT 0 DESTRUCTION LJ <br /> PUMP INSTALLATION'' SYSTEM.REP.AIR d OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK .SD* SEWER LINES DISPOSAL FLD. POOP. LINE <br /> l FOUNDATION AGRICULTURE WELL S OTHER WELL I.�! PITSISUMPS W r <br /> INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS %r <br /> ❑ Industrial P <br /> en Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> T e I Casing' �� `Specifications <br /> �omestic/Private ❑-Gavel-Pack' '" -'D'Tracy 'T"' YP .❑ Other II Delta Depth of Grout Seal - Gx ,�Tyge qfl Grqu <br /> f 1 Public <br /> I I Irrigation __Approx. Depth 4 I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P, —;;Z— 1 State Work Done <br /> '{ Sealing Material (top 50.') <br /> Well Destruction ❑ Well Diameter "r , Jr <br /> h! ` Filler Material (Below 50'1 S <br /> F Depth � - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 1 DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will'serve: Residence L Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:- Water table depth <br /> }^ 4 <br /> NaCompartments <br /> SEPTIC TANK ---B---Type/Mfg Capacity , <br /> PKG. TREATMENT PLT. 171j li Method of Disposal <br /> Distance to nearest: Well' Foundation Property Line i <br /> I LEACHING LINE ❑ No. &;Length of Eines r <br /> •`. I Total length/size <br /> i FILTER BED L1Distance to nearest:Ai Well Foundation Property Line <br /> ,. <br /> SEEPAGE PITS I l Depth: - Size Number <br /> SUMPS 11 Distance to nearest: Well Foundation Property Line # <br /> i DISPOSAL PONDS ❑ - I <br /> Y <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, and <br /> rules and regulations of the San Joaquin Local Health Di§trict. ' <br /> Home owner or licensed agent's signature certifies the following: "l certify that in the performance of fhe"wcI for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's <br /> compensation laws of California." Contractor's hiring or sub-contracting signature l <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." f f <br /> The applicant mustall for all requir d inspections. Complete drawing on reverse side. -. <br /> Signed X <br /> 'Title-- _14 Date: g <br /> FOR DEPARTMENT USE ONLY _ -r r <br /> �^+ F <br /> Application Accepted by Date Area OT/ <br /> I Pito t spection by Date <br /> GrouFinal Inspection by Date 4 <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 Ava., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. <br /> INFO 1 <br /> +,EH 13-24(REV.t/n sf <br /> EH 14-2e <br />