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F <br /> a <br /> i APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 'I YEAR FROM DATE ISSUED A, <br /> 4 (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 /> e 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 sewag <br /> Local Health District. y �,, / <br /> Job Address /l �� l97 y �ayG- _ City <br /> -��K�. Lot Size � '�«a - PM <br /> j� 98i-s <br /> Owner's Name � m��� �� � — Address �3�� - ��T G Phone <br /> Contractor's Name t License.No.�;�Z rY7 — Phone; ? <br /> TYPE OF WELL/PUMPA NEW yyEL-Lr❑` WELL REPLACEMENT D --,DESTRUCTION-(S <br /> r�- i <br /> PUMP INSTALLATION ❑ ; ; SYSTEM REPAIR 12 "i �c ° OTHER❑ j <br /> 1 t/ DISPOSAL'FLD. � JPROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK t: 114- SEWER LINES r " - <br /> a R t <br /> i FOUNDATION AGRICULTURE WELL/! GTH R WEAL =1 PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA# CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom O,Mahteca Dia- of Well Excavation a Dia. of WeI[ICasing <br /> c - ,Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy of Casing <br /> EType of Grout <br /> El Public 1 ❑ Other , ❑ Delta Depth of Grout Seal <br /> El Irrigation �pprox. Depth C3 Eastern Surface Seal Installed by ) <br /> l <br /> Repair Work Done ❑ Type of Pump ` H.P. <br /> State3Work Done i f <br /> I Sealing Material (topa60') "� f ` <br /> Well Destruction ❑ Well DiameterY.i1'�� l r <br /> Depth Filler Material (B@Iaw`50') ' 0 <br /> TYPE OF SEPTIC WORK: NEW INS}ALLATIO` 'Of REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within'200 feet.)'=f' <br /> / x <br /> Installation will serve: Residence ' Commercial_ OtheI s �h <br /> Number of living units: Number of bedrooms ' { # <br /> Character of soil to a depth of 3 feet:` CL Water table depth 1 <br /> SEPTIC TANK '❑ Type/Mfg <br /> Capacity No. Compartments S <br /> PKG. TREATMENT PLT:❑ Method of Disposal <br /> Distance to nearest: Well L Foundation Property Line <br /> t e l <br /> LEACHING LINE a;��. ength of lines � Total length/siz � <br /> FILTER BED �j� Distance to nearest: Well Foundation Property tine j <br /> -i <br /> SEEPAGE PITS 11Depth I / Size L Number r <br /> SUMPS URe""DistanC2 to nearest: Well Foundation--!!Z 4 - Property Line '7.67 { <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. <br /> Home owner or licensed agent's ssighature certifies the following:-"l`Ca ify-that-in-the perfotmance-of the work,for'whic"is-permit is issued, I shall not <br /> I 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 /> 4 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 Calllfornia.".. <br /> The applicant must call for all required inspection Complete drawing on reverse side. <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY 6Zj <br /> , <br /> Application Accepted by Date Area F� p� <br /> K -Pit'or"Grout4nspection by Date <br /> Final Inspection by Date <br /> V� <br /> Additional Comments: <br /> �G Sik 466 6781 [I Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 6385 <br /> * plicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, 5tk.`GA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. <br /> y INFO CASH . <br /> a 111 13-24IREV.101831 <br /> 14 1428 <br /> i' <br />