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♦r Y <br /> 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 DistrictA— <br /> P�Q �•7 <br /> Job Address _�� .bd, PR✓/EST 2.D city—.FLot Sits X PM D3 / <br /> Owner's Name C_/F Address <br /> - _ Phone 10 <br /> Contractor's Name _ FL-0YDGUOQ LIcense No 444to Phone 3C171 <br /> TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL_ PITS/SUMPSr- <br /> INTENDED USETYPE OF WELL r PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C Industrial ❑ Open Bottom E Manteca Dia. of Well Excavation� Dia. of Well Casing <br /> G Domestic/Private a Gravel Pack ❑ Tracy Type of Casing_.._ Specifications <br /> ❑ Public ❑ Other ff`Delte Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done C Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filfer Material (Below SO') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (Nof <br /> septic system permitted if public sewer is <br /> / available within 200 feet.) <br /> Installation will serve: Residence_t Commercial_ paler <br /> Number of living units: Number of bedrooms 3 <br /> Character of soil to a 7 of 3 feet: -SA A/A Water table depth <br /> SEPTIC TANK Type/Mfg Capacity-JJPOa No. Compartments Zi <br /> PKG. TREATMENT PLT. ❑ 1 / I - ' Method of Dispbsal <br /> Distance fnearest: WellF <br /> oundation /A Property Line <br /> LEACHING LINENL' o. & Length of lines _ _- 949 Total length/size _ <br /> FILTER BED ❑ Distance to nearest: `- Well—61 Foundation—1 _ Property Line 24 <br /> it\ <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest; Well Foundation Property Line <br /> DISPOSAL PONDS 17- <br /> I <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 11c"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 must call for a} requ1fe31ns eMlons.'-Complete-c iawing on reverse side. <br /> Signed k`_�:__ - <br /> Title: Date: <br /> FOR DEQAR ENT USE ONLY <br /> Application Accepted by ^�� rata �J Area <br /> Pit or Grout Inspection by Date Final Inspection b <br /> Y Date a�y - <br /> Additional Comments: <br /> ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8356385 <br /> Applicant- Return all copies to: Environmental Health Pemlit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO CASH RECEIVED BY DATE PERINfT T10. <br /> . CKi- <br /> EH 74�3-27(REV.1O1e3Y 5 .. _ � ���`P.5 <br /> EH 1gs—leg <br />