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-1,­­- yall-------3rr..-rr.-,--� <br /> + APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT z i <br /> 1601 .E". HAZELTON AVE., STOCKTON, CA _ <br /> Telephone (209) 466-6781 r Z <br /> PERMIT EXPIRES VYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a <br /> permitand/or <br /> the work herein described. This <br /> made in compliance with San Joaquin County Ordinance No.549 for sewageor No.1862 forowellpump andthehe Rules and Regulations of the SanapPlication <br /> Local Health District. # <br /> Job Address471Q <br /> City /!1�Lot Size PM <br /> Owner's Name Address !f <br /> ' � Phone �� 7 <br /> Contractor � � � Address <br /> License No. _Phone_ <br /> E OF WELL/PUMP:. NEW WELL ❑ _ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ ' <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ <br /> ' SEWER LINES` DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ! <br /> INTENDED-USE TYPE OF WELL PROBLEM AREA. CONSTRUCTIONf'-SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca € Dia- of Well Excavation <br /> ❑ Domestic/Private Dia. of Well Casing <br /> ❑ Gravel Pack` El Tracy n Type of Casing A .-� <br /> y Specifications <br /> i'l Public J f_l Other Cl Delta Depth of Grout Seal <br /> Type of Grout <br /> I I Irrigation <br /> --Approx. Depth I I Eastern <br /> Surface Seal Installed by # -_ <br /> Repair Work Done 0 Type of Pump _ H.P, <br /> Well Destruction ❑ Well Diameter State Work Done <br /> `�. Sealing Material (top 50') + j <br /> Depth Filler Material (Below 50') �I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION i I DESTRUCTION [11,W&septic system permitted if public sewer is <br /> ef available within 200 feet-1 <br /> Installation' will serve: Residence� ��Commercial= Other - <br /> Number of living units: Number of bedrooms <br /> Character.of-soil to a depth of 3 feet: <br /> SEPTIC TANK Water table depth <br /> ❑ Type/Mfg ' Capacity No. Compartments (� <br /> PKG. TREATMENT PLT. ❑ y <br /> Method of Disposal <br /> Distance to nearest: Well Foundation <br /> Property Line <br /> LEACHING LINE Cl No. & Length of lines <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well <br /> .� Foundation Property Line <br /> SEEPAGE PITS l I Depth Size <br /> SUMPSNumber <br /> L7 Distance to nearest: Well Foundation <br /> DISPOSAL PONDS LlProperty Line <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 taws, and F <br /> rules and regulations of the San Joaquin Local Health District. <br />{w Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not <br /> 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 /> 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." <br /> he applicant st II for I required inspections. plate drawing n verse side. Ir (jL..Y1GY <br /> Signed X <br /> Title: 5' � In,Qr`j <br /> ' "mate: <br /> �� FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date Area Y <br /> Pit or Grout Inspection by Date r Q� <br /> t Fin f IIn ction by Date ` d <br /> - (o r <br /> Additional Comments: i <br /> ❑ Stk 466-6781 ❑ Lodi -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, Stk., CA 95201 <br /> i <br /> FEE AMOUNT DUE AMOUNT REMITTED CK y <br /> INFO C SH RECEIVED BY DATE PERI I7-NO- <br /> + EH 13-241pEV.1i85y ��� !J <br /> EH 14-28 1,0 <br />