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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON ON 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 sews r No. 1962 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. ` SC g 111 <br /> {�� �� <br /> Job Address . 0 '' -�7' U7 ; 1y City Lot Size _ PM <br /> Owner's Name �d �v n r__,Y A.' l Address ` I ,�„ Phone <br /> � x <br /> Contractor Ivo tA��1 y`,�1-Z>G l'lLrDA G Address Op (i I m License No.9� 8 �. Phor � <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION O <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER J? MOA11/.,& `y am <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 <br /> Dia. of Well Casing <br /> 0 Domestic/ rival LxGravel Pack ❑ Tracy Type of Casing pv Y �� y <br /> 9— Specifications C L 11,- <br /> FI Public ❑ Other FI Delta Depth of Grout Seal IM k 14` 6�_ Type of Grout <br /> I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by { <br /> Repair Work Done U Type of Pump H.P. _ State Work Done _ <br /> Well Destruction O Well Diameter M�� 9� <br /> �� Sealing Material (top 501 8 <br /> Depth -. Filler Material (Below 50'1 SA M 0-r& 4 �L�,,. ,, <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR%ADDITION I 1 DESTRUCTION ( I (No septic system permitted if public sewer is <br /> Installation will serve: Residence­— Commercial— Other available within 200 feet.) <br /> Number of living units: Number of bedrooms / <br /> Character of soil to a depth of 3 feet: Water table depth <br /> PKG. TREATMENT PLT. ❑ <br /> SEPTIC TANK O Type/Mfg `� Capacity - No. Compartments <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I Depth _Size Number _ <br /> SUMPS Ll Distance to nearest: Well Foundation <br /> 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 subiact to workman's compensation laws of California." Contractor's hiring or sub is <br /> sig <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman' nature <br /> S com nature <br /> tion laws of California." <br /> The applicant st call for all required i tons. Complete drawing on reverse side. <br /> Signed X_ 11- 2-9-7 <br /> Title: �_ � � - Date: <br /> FOR DEPARTME T USE ONLY <br /> Application Accepted by DateArea <br /> �7 <br /> 1 <br /> Pit or Grout Inspection by _.Date` Final Inspection by Date <br /> Additional Comments: <br /> ❑ 5tk 466-6781 ❑ Lodi 368-36210 Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E_ Hazelton Ave,, P.O, Box 2009, Stk., CA 95201 <br /> ry <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO RECEIVED BY r' DATE PERMIT NO. <br /> EH 1341(REV.t n si <br /> EH 11.20 <br />