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APPLICATION FOR PERMIT J• <br /> SAN JOAQUIN,LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA ' <br /> Telephone (209) 466-67$1 . <br /> PERMIT EXPIRES 1 YEAR,FROM DATE.ISSUED , <br /> s„- a i< {� i7 ':r� {Complete in Triplicate).."�, a�.ftt3i:'I w . . <br /> x.. <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 r <br /> (..made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/purnp,and the Rules and Regulations of the San Joaquin <br /> Local Health District. Y <br /> .Fob Address �� `�i <br /> I. , Gty , Lot Size PM <br /> Owner's Name Y,- , L IZI � -Address - _ -- <br /> Phone <br /> Contractor M. L ; Address a50 C_ License:No. Phone i <br /> TYPE OF WELL/PUMP: t. NEW WELL, Ll WELL REPLACEMENT ❑ DESTRUCTION i❑ <br /> PUMP INSTALLATION.Q SYSTEM REPAIR ❑ ' OTHER '❑ <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 SPECIFICATIONS ` <br /> ❑ Industrial ❑ Open Bottom ❑ 'Manteca Dia. of Well Excavation ! Did. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing € Specifications <br /> ❑ Public ❑ Other ❑j Delta Depth of Grout Seal 1 p Type of Grout <br /> ❑ Irrigation --Approx. Depth f ❑ Eastern Surface Seal Installed byF <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') y 4 9 <br /> Depth t Filler Material Below 50') 4 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION f eptic 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 t <br /> Character of soil to a depth of 3 feet: r } <br /> ' Water table depth <br /> SEPTIC TANK ❑ Type/Mfg j Capacity t No. Compartments <br /> PKG. TREATMENT PLT- El <br /> It *4.1f-r _, _ r f t r* Method of Disposal <br /> Distance'to nearest: Well Foundation! -' vPioperty Line <br /> LEACHING LINE ❑ No. &f Leri tfi-of lines _T <br /> g Total length/size � <br /> FILTER BED ❑ Distance to nearest:• 4-Well Foundation Property Line <br /> SEEPAGE PITS O DothSize -� 1 <br /> Number <br /> SUMPS ❑ Distance to nearest: Wel! Foundation o Property Line _ <br /> DISPOSAL PONDS Cl <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:._ �, ,- V i <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, ! 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 /> ce s 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 fa f CaGfarna. - <br /> applic t cal! r al equir ins ion C mplete drawing on verse side f <br /> Signed Title: / <br /> Date: <br /> FOR DEPARTMENT USE ONLY ` Q" t <br /> Application Accepted by DateC� J/ �U Area D ' <br /> ' Pit of Grout Inspection by Date Final Inspection by /�f -�� Date <br /> Additional Comments: i <br /> ❑ Stk 466-6761 ❑ Lodi �t/Services <br /> . 823-7104 ❑ Tracy 8355-6385 <br /> Applicant- Return all.copies to: 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br />