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s } <br /> APPLICATION FOR PERMIT <br /> a. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL—ION AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> # PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> � (Complete in Triplicate) <br /> t an Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> Application is hereby made to the S 4 or No. 1862 for well/pump 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. <br /> q CityLot Size PM <br /> Job Address <br /> _ <br /> T-44 12/9 _r 8 Address a� ' z� Q Phone <br /> Owner's Name � <br /> t Qr)?7 5EI, d <br /> Contractor <br /> � f /,/,$ Address L-Gp License No. �� Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DES7RUCT1OR ❑ <br /> PUMP INSTALLATION, 16r"--4;W11 7/STEM REPAIR ❑ OTHER ❑ <br /> DISPOSAL FLD. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ti <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation i <br /> Type of Casing + Specifications <br /> GYAomestic/Private ❑ Gravel'Pa ❑ Tracy T of Grout <br /> �'C❑ Public ❑ Other I ❑ Delta Depth of Grout Seal Type <br /> 4 <br /> ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by ; <br /> Repair Work Done C1Type of Pt mp H•P• State Work Done—`{ <br /> Sealing Material (top 50'1 <br /> Well Destruction ❑ Well Diameter g <br /> Depth t Filler Material (Below 501 l <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [IREPAIR/ADDITION C3DESTRUCTION ❑ (No septic tern permin feet ted if public sewer is <br /> Installation will serve: Residence= Commercial, Other <br /> Number of living units: Number of bedrooms Watertable depth <br /> Character of soil to a depth of 3 feet:: No. Compartments <br /> i SEPTIC TANK ❑ Type/Mfg Capacity 1 <br /> i Method of Disposal <br /> PKG. TREATMENT PLT. Cl <br /> Distance to nearest: Well Foundation Property tine; <br /> Total length/size <br /> LEACHING LINE ❑ No. &Length of lines Property Line <br /> FILTER BED ❑ Distance to nearest: Well Foundation p rtY <br /> i,I i <br /> SEEPAGE PITS ❑ Depth i'I Size Number } <br /> ❑ Distance to nearest: Well Foundation Property Line ,.�«.. <br /> SUMPS <br /> A <br /> DISPOSAL-PONDS" ❑ <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 District. rk for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the wo <br /> ' employ any person in such manner as!to become subject to workman's compensation 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 shall employ persons subject to workman's compensa <br /> tion laws of California." 1 <br /> The applicant f all re n ctlons ompl�etedrawing-onievveetse_ ide.. f g <br /> "I-%,- <br /> a— Date: <br /> Signed - •\ Ti Ie: _ 1 <br /> R DEPAR-MA N.i USE ONLY <br /> �, Date z'3 — 1 <br /> Application Accepted by '" <br /> f ction by <br /> Pit or Grout Inspection <br /> ,i,/, ate Final Ins <br /> Additional Comments: ! �� <br /> ❑ Stk 466-6781 ❑ Lodi 369,3621 ❑0Aantecaj'823 7104 ❑ Tracy 8356385 I <br /> tk., CA 95201 <br /> Applicant- Return all copies to: Environmental Health Perri Services a 1601»E. Haazzellton Aver P O. Bo $ tl <br /> FEE AMOUNT OUE AMOUNT REMITTFD ,CASH a`' RECEIVED BY DATE PERMIT ND. <br /> INFO <br /> EH 1426 <br />