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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 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. 1862bor well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address le If 00 J6 1ZA14 ^ City Lot Size PM <br /> ��// f �p <br /> Owner's Name �� !�/ Address L�!/� �[� Phone a <br /> ContracIor f4,6 L <br /> C- <br /> Address/��7-?/�� r�License No.Ae Phone <br /> TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ie OTHER ❑ ` <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES * DISPOSAL FLD. PROP. LINE } <br /> FOUNDATION AGRICULTURE WELL4 OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r <br /> L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> .WDomestic/Private El Gravel Pack ; '❑ Tracy Type of Casing I Specifications <br /> ❑ Public ❑ Other f ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. _ State Work Done a" <br /> O[ !W' I Well Destruction �'1�Well Di eter Sealing Material (top 50') <br /> t Filler Material (Below 501 <br /> TYPE OF SEPTIC OR NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <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: Water table depth <br /> SEPTIC TANK ❑;'Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> �i Distance to nearest: Well Foundation ..-_Property Line <br /> LEACHING LINE ❑ No. & Length of linesWTotal length/size <br /> FILTER BED ❑ Distance to nearest: Well ,,FoundatiorE' Property Line E <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line = - <br /> DISPOSAL PONDS ❑ <br /> 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 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 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 /> The applicant st all required inspections. Complete drawing o verse side. <br /> Signed Title: Date: 0 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted b00 <br /> y Da ��Z/ ^ —T t- „1� <br /> f�- <br /> Pit or Grout Inspection by Date Final Inspection by I--- <br /> Date• <br /> " { �•a S <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 +;`, 3 �j > <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CAe95201 C3 <br /> _-••may ri.a r>r"k <br /> �i <br /> '•A <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 9Y DATE � IT`NO. <br /> + EHt426fREV.i/e5Y ��. OO �Zzr <br />