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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 F —0/ <br /> I� PERMIT EXPIRES 7'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 /> fnade 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 1 Lot Size PM <br /> Job Address �j �] <br /> �" /ddress '/� Phone ! ✓I / <br /> Owner's Name <br /> ,r F contractor e00/ _ Address D License No, /Phone � � <br /> ® TYPE OF WELL/PUMP:-----. NEW WELL El <br /> PUMP <br /> ❑ DESTRUCTION 171 .� <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ —OTHER <br /> ❑ �� <br /> e..,. a <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ' PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> II - ` <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , <br /> I� industrial ❑ Open Bottom Q Manteca .Dia. of Well Excavation Dia. of Well Casing <br /> ,I € <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> Delta s <br /> [`i Public- .. .- Cl Other C1 ltaDepth of Grout Seal Type of Grout <br /> ll I irrigation r y _.Approx. Depth I i Eastern Surface Seal installed by - <br /> o <br /> 't"tepak Work Done ❑ Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ ,Well Diameter "t Sealing Maferial ((top 50'1 " <br /> Depth Filler M f3el w 50'I i <br /> t TYPE OF SEPTIC WORK: NEW INSTALLATION I i.._�REPAI ADDITIO DESTRUCTION I 1 iNo septic system permitted it ublic sewer is O <br /> le hip 200 feet.] ' <br /> ��( <br /> Installation will serve: Residence '�^Commercial Other ��avail <br /> '+ Number of b4drooms fiC/ <br /> Number of living units. ��/0 x <br /> Character of soil to a dFthof 3 feet: 6 - - Water table depth <br /> SEPTIC TANK , ❑ Type/Mfg `- Capacity No. ConhpartmentsA. s <br /> PKG. TREATMENT PLT. O f Method pf Disposal <br /> _,;r,,,...�.._Distanceao nearest:-. Well Foundation Property.Line <br /> LEACHING LINE ❑ No. & Length of-lines Total length/size <br /> t 'FILTER 8EO ❑ Distance to nearest: Well Fo ndaation Property Line <br /> 1 <br /> ,+ SEEPAGE PITS I 1 Depth Size �* Number <br /> /> <br /> +, ,SUMPS Distance to nearest: Wel Foundation Property Line t <br /> DISPOSAL PONDS ❑ — .�.— <br /> is I hereby certify that I have prepared this application and that the work will be done in accordance with S`an Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District ' <br /> C 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, I 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 follawin : <br />