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E APPLICATION FOR PERMIT <br />' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES ll 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 Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. -{- <br /> �} City L Y' D of Size x CO PM <br /> Job Address v � D -�' <br /> Owner's Nam,,ZDNS._� (�-C) o NCC Address Phone <br /> _ __,.. �_ v�_ ..a_ �a�'•- �� .. Phone � <br /> Contractor's Name. �- License No: <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 /> -=f r.� <br /> El Industrial 1�11 Open Bottom 3 • El Manteca Dia. of Well Excavation Dia. of Wel! Casing <br /> ❑ Domestic/'Private El Gravel Pack 1( ❑ Tracy Type of Casing Specifications <br /> ❑ Public 'r[:] Other #❑ Delta Depth of Grout Seal Type of Grout <br /> Ll Irrigation ---Approx. <br /> D, 'h-'1- ❑ East erner, Surface Seal Installed by , , <br /> Repair Work Done ❑ Type of Pump -- - ;H.P. State Work Done <br /> Well Destruction 1-1WellDiameter ;Sealing Material itop 50'1 <br /> Depth .', =Filler Material (Bebw 50'1 s 0 <br /> TYPE OF SEPTIC-WORK: NEW"INSTALLATION,❑' REPAIRIADDITION L-•'C3ESTgUCTION F1 (No septic system permitted if public sewer is <br /> t available within 200 feet.) <br /> Installation will serve: Residence`� c=ommercial Other <br /> Number of living units:LA 11 Number of bedrooms <br /> ! Character of soil to a depth of 3 feet:I Water table depth <br /> SEPTIC TANK f ❑ Type/Mfg, = Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ _. Method of Disposal <br /> Distance to nearest:" Well Foundation Property Line <br /> F <br /> gth-of-ine -_LEACHINGfLINE �l�o. &-Lenj ' length,yamTota! size <br /> FILTER BE/' 1-1Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS a;-*"Depth Size //�� --,� �Number <br /> SUMPS ❑ Distance to nearest: We 11 //1s�'�L� I Foundation -= Property Line <br /> DISPOSAL PONDS ❑ t r .� <br /> I hereby certify that I have prepared this applicati6n`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.Dist-rict. <br /> Home owner or licensed agent's signature certifies the.folidwing: "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 became subject to workman's corrlpensation laws of California." Contractors 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 shaft employ persons subject to workman's compensa <br /> 7Tdo of California." .T <br /> he of Ca <br /> s for <br /> requ'``" <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> .Application-Accepted-by,^- Date-1pa,Z--'8-'A—Area-- --D- _ _ <br /> k <br /> Pit or Grout Inspection by Date - J Final knspectlon by ` Date A-1- 1-191 <br /> Additional Comments: <br /> r E] Stk 466-6781 ❑ Lodi 36.43621 ❑ Manteca 823 7104 ❑ Tracy 835 6385 <br /> --A.--Applicant---Retum-all-copies-to:-Environmental-Mealth=Permit/Services-,1g601-E 1 lazelton-Ave.-P:O-Box-2x09,-Stk:;-CA-95201 _ <br /> FEEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO - . <br /> DD 43 <br /> + EH 13-24 IREV.10!83} <br /> EH 14-28 <br />