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55 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> 1601 E. HAZE T 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 /> or No. 1862 for well/ and the flutes and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage <br /> Local Health District. <br /> 01 City Lot Size PM <br /> Job Address �. <br /> �. Phone �� G 230 <br /> Owner's Name ��� � �V 1 Address �// �] <br /> Contractor's Name <br /> A C P-1S H *SO\-)!cense No. 12 .5� �� Phone 7 C�� l�� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ OESTRUCTlON ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR E: OTHER ❑ { ^ <br /> DISPOSAL FLD. PROP. LINE " `! <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES .._ _ __ _.— -_ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS y� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dla. of Well Excavation <br /> Dia. of Well Casing <br /> L3 Industrial ❑ Open Bottom El Manteca <br /> Type of Casing Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Grout <br /> ❑ Public ❑ Other El Delta Depth of Grout Seal yp <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump <br /> H p State Work Done <br /> Wel! Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION C3 REPAIR/ADDITION ❑ DESTRUCTION (Nao seilabpelwithin 200 feetm per .) if public sewer is <br /> Installation will serve: Residence—C Commercial_ Other <br /> i <br /> Number of living units: Number of bedrooms , <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ 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 ❑ Depth Size Number <br /> SUMPS ❑ Distarice to nearest: Well Foundation 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 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 a or all require cti ns. omplet rowing on reverse side <br /> Signed ~� "� Title: <br /> � -y'+,.��—'J _ Date: <br /> FOR DEPARTMENT USE ONLY <br /> Date �� Area Q <br /> Application Accepted by <br /> Pit or Grout Inspection by j f 1 <br /> Date Final Inspection by D -� — <br /> ;t <br /> Additional Comments: 'v <br /> :R��6 1— <br /> El Stk 466-6'781 0 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-5385 <br /> Applicant- Return all copies to: Environmental Health Permit/Se+vioes 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEEK RECEIVED BY DATE PERMIT'NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASHC <br /> +EH 1324(REV.10163) US7 <br /> EH 14-26 ��—►17Z/ t <br />