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APPLICATION FOR PERMIT <br />SAN JN LOCAL HEALTH DISTRICT <br />1601 E. HAZELTON AVE., STOCKTON, CA <br />Telephone (209) 466-6781 <br />PERMIT EXPIRES I 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. I <br />Job Address &V <br />Owner's Name iall� <br />Contractor <br />::�0414 06t1--- *_ <br />4-_�A City 5� ACJ Lot Size PM <br />Address �Ay&*-ca ft's Phone <br />7 <br />Address 6�46 4 5 (_ 4��d License No. 4a /9 2-le/e. Phone e/v/s) gmo <br />TYPE OF WELL/PUMP: NEW WELL ;K WELL REPLACEMENT El DESTRUCTION 0 <br />PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER V p.CeXfOAJle <br />DISTANCE TO NEAREST: SEPTIC TANK <br />SEWER LINES — DISPOSAL FLD._ PROP. LINE <br />FOUNDATION <br />AGRICULTURE WELL — OTHER WELL PITS/SUMPS <br />INTENDED USE <br />TYPE OF WELL <br />PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />Kindustrial <br />0 Open Bottom <br />0 Manteca Dia. of Well Excavation Dia. of Well Casing —Z <br />• Domestic/ Private <br />,-CKGravel Pack <br />0 Tracy Type of Casing z Pet Specifications <br />• Public <br />0 Other <br />0 Delta Depth of Grout Seal -3r — Type of Grou <br />El Irrigation <br />1-1!ffApprox. Depth A Eastern Surface Seal Installed by <br />Repair Work Done <br />El Type of Pump <br />H.P. State Work Done <br />Well Destruction <br />0 Well Diameter <br />Sealing Material (top 501 <br />Depth <br />Filler Material (Below 501 <br />TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION 0 (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: <br />SEPTIC TANK 0 Type/Mfg <br />PKG. TREATMENT PLT. El <br />Water table depth - <br />Capacity No. Compartments <br />Distance to nearest: Well — Foundation <br />LEACHING LINE El No. & Length of lines <br />FILTER BED El Distance to nearest: <br />Well <br />Foundation <br />Method of Disposal <br />Property Line <br />Total length/size- <br />- Property Line <br />SEEPAGE PITS 0 Depth Size Number — <br />SUMPS 0 Distance to nearest: Well Foundation — Property Line <br />DISPOSAL PONDS 0 <br />1 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 applicanTt call for II required inspections. Complete drawing on reverse side. <br />Z_7t --, a --I— <br />Signed X Title: Date: 04-92 <br />I <br />r50__ RIP T USE 01 <br />Area <br />'01 '100- <br />-.511i li� 12M. -r Date <br />•­­ W.Vn by Date — Final Inspection by Date <br />A MOU NT REMITTED <br />