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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 /> ,. <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 4. <br /> (Complete in Triplicate) t � <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install XRulesd <br /> bed. FnT 's application is <br /> made in compliance With San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and tns of the San Joaquin <br /> Local Health District. /Job Address 4F L l� City Lot Size PM <br /> s Owner's Nam a L?�. yAd4ress = U 5 J1lne 4h, <br /> Contractor's Name "� License No. � / Phonease/ <br /> TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION�❑ ,�, SYSTEM REPAIR ❑ OTHER ❑ a f <br /> , <br /> DISTANCE TO NEAREST: SEPTIC TANK 1.. SEWER LINES DISPOSAL FLD, IIV PROP. LINE f ? <br /> FOUNDATION-=—C — AGRICULTURE WELL OTHER WELL s PITS/SUMPS Q <br /> ANTE. USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S - �44 xt <br /> ❑ Iridusbal pen Bottom ❑ Manteca Dia. of Well Excavatio rL Dia. of Well Casing <br /> amestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications '�'6 <br /> ❑ Plublic ElOther C3Delta Depth of Grout Seal Type of Grout w <br /> °❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> R; it Work Done ❑Type of Pump H.P. State Work Done <br /> tn/e1 Destruction ❑ Vi%ell.:Diameter Sealing Material (top <br /> Depth Filler Material (Below 501 <br /> TY P OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> - available within 200 feet.) <br /> apirt itallation will serve: Residence_ Commercial Other <br /> Nituber of living units: Number of b Brooms <br /> -,.CI aracter of soil to a depth of 3 feet: N Water table depth <br /> SEPTIC TANK ❑ Type/MfgCapacity No. Compartments <br /> r. SE <br /> PK�. TREATMENT PLT. ❑ <br /> -i,, Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEA HING LINE ❑ No. & Length of lines *1�11 v .� Total length/size <br /> FILIER BED ❑ Distance to nearest: Well Fodhdation Property Line <br /> i <br /> SEE AGE PITS El.„-Depth Size Number <br /> Suh PS ❑ Distance to nearest: Well Foundation r Property <br />-.,-�"�..r=---='- �-�-;;_+�`�.-�w,�•.:�,=.a--� -:� .-�_.�.- .� ,.._ Line <br /> SIS OSAk. PONDS ❑ x j .- � ,.. :.,_�-... m_—, ;:.. _-�. r. - _ _ _ <br /> 11 hei aby certify that I have prepared th s application and that the work will be done in accordance ith,San Joaquin county ordinances, state laws, and <br /> .,rulei and regulations of trT6_S!tr Joaquin Local Health District. <br /> Norr a owner or,licensed' ent.s si nature certifies the following:� :.nsed� g , .rg g: "!terrify that in the performance of the�ly,�ofk for which this permit is issued, I shall not <br /> emp yany-person:in•such anrrer as to become subject to workman's compensation laws of California."CorAractor's hiring or sub-contracting signature ; <br /> cerci ies the following: '1 certify that in the;performance of the work for which this permit is issued,I shall emploj rsons subject to workman's compensa- 1 <br /> Ition'aws of California." <br /> The 6plicant r all requilied inspect omplete drawing on reverse side. <br /> Signed Jf, Title: `+�►'L.U� >�' _ Date: ` <br /> Fop DEPARTMENT USE ONLY y a: <br /> App y n ccepted by Date r�v Area <br /> .-AW -or•Gr .Inspection,6y - te° tnal Inspectionwby- _ - Date <br /> Additional Comments: <br /> ❑Stk 466-6781 ❑ L 369-3621 ❑ Manteca 823-71a iracy ' 635=6385 f <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. azeltan Ave., P.O. Box 2009, Stk., CA-95201FEE i <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. <br /> (REV.10!831 <br /> EH 1425 r � /aC <br />