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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 <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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address - - r i i—+Y-r--- City <br /> Lot Size PM / <br /> Owner's Name )" 00 Golf Address -22- 1 W 105 r 7 Ne `� Phone 33- 67a Jp <br /> Contractornlr � lI C/ icense No.v2 _4 <br /> Phonss <br /> TYPE OF WELL/PUMP: NEW WELLX WELL REPLKCEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 9 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well ExcavationDia. of WOK Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 5'.6,41 Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Z! Type of Grout CtoMP <br /> ❑ Irrigation _Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done Q <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> II , <br /> /i017,T�p1 N/C�� Depth 1; Filler Material (Below 50'1 <br /> TYPE OF S TIC W. <br /> NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> 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: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well - Foundation Property Line <br /> LEACHING LINE ❑ No. III Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <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 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 subcontracting 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 applican must call for allpuire io . Complete drawing <br /> /onnrreverse side.,,//r I m <br /> Signed Title:7(//I G('�9����'g 1/9 r Date: <br /> FO EP T BE ONLY <br /> Application Accepted b Date — Area <br /> Pit or Grout Ins do • Date A•'--i Final Inspection by Date 3e G' [ <br /> i <br /> Additional Comment <br /> ❑ Stk 4664761 ❑ Lod 369-3&1 ❑ Manteca 823-7104 Z ❑ Tracy 5-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> IN AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. <br /> �c <br /> EH 13-711REV.vest --ac,,. <br /> -1 l <br /> EM IL28 �J. O'O � � 1D <br />