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APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZEL TON 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 HaeM Eli alat for a perrnk to construct and/or install the work herein described. This application is <br />made in compliance with San Joaquin County Ordinanoa Na. 50 for sewage or No. 1862 for vy4JpwM and the Rules and Regulations of the Son Joaquin <br />Local Health District, 02- 2- <br />&j " Z <br />Job Address es — city eke I'M <br />4da <br />11237j <br />Contrarctot's Name <br />rise No. Iry <br />I -RI. <br />TYPE OF WELLIPUMP. <br />NEW VVM C WELL REPLACEMENT 0 50;7c�TION 0 <br />PLIMP INSTALLATION r. SYSTEM REPAIR P-' I I OTHER 1: <br />DISTANCE TO NEAREST- SEPTIC TANK SEWER LINES — DISPOSAL FLO.— PROP. LINE <br />FOUNDATION AGRICULTURE WELL — OTHER WELL PITSISUM" <br />INTENDED USE <br />TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />0 Ind usVied <br />13 Open Bottom. . -0 Manteca Dia. of Well Excavation Dia. of well Cst I <br />Z Dornastik7ftWM <br />IJ Gravel Pack 0 Tracy Type of Casing— Specifications <br />Z Public <br />M Other C Delta Depth of Grout Sod Type of Grout <br />m4rigat"::—Approx. Depth 0 Eastern Surface Seel Ins by <br />Repair Work Done <br />Aid <br />"Ty of PUMP H.P. 1-5, — State Work Don, 4;tr/,d CA, <br />Well Destruction 12 <br />Well Dlarnater Sealing Material atop 517I <br />Depth Pular Mat" ("OW 501 <br />TYPE OF SEPTIC WORK: <br />NEW INSTALLATION 0 REPAIRIAWTION El DESTRUCTION 0 (No septic system parmittedif public sawar is <br />available within 200 feet) <br />installation Ad serve: <br />Residence — Commercial — Other <br />Number of living unft-. — Numbar of bedrooms <br />Character of sail to a depth of 3 feet: <br />SEPTIC TANK 0 Type/Mfg <br />PKG. TREATMENT PLT. 11 <br />Distance to nearest: <br />—es <br />LEACHING LINE C No. & Length of Ik <br />FILTER BED C Distance to nearest <br />Water table depth <br />Capacity No. Compartments <br />Method of Disposal <br />Wag — Foundation <br />Well Foundation <br />— Prop" Line <br />Total lengthtaize <br />— Property Una <br />SEEPAGE PITS C, Depth size Number — <br />SUMPS n Distance to nearest. Well — Foundation — Property Line <br />DISPOSAL PONDS 13 1 <br />I hereby certify the I have prepared this application " that the work will be done in accordwyce with San Joaquin county ordinances, state laws, and <br />ruies and regulations of the San Joaquin Local Health District. <br />Home oz or r lic?�sgenes signature certifies the following. "I certify that in the perforrnvi" ance of the for w0lich this permit is Wkied, I shell not <br />—PIG) n we mannier as to become subject workman's ompensation Uwe of California." Contractor's hiring or sub -contracting signature <br />Zn is of <br />- rtmrjee tPomrl.," .,lowing: "I that in the work for which this permit is issued, I *had employ persons subject to workman'* corr">ansa- <br />Calif <br />The ap, lilwt r14 f all r n drawing on de. <br />Signed- ride: 0.: <br />lox( <br />DEPARTMENT USE ONLY <br />Application Accepted by ciL L <br />Pit or Grout Inspection by Final Inspection by Dam <br />Additional Comments. <br />7 Stk 486-8781 0 Lodi 368-3821 0 Manteca 823-7104 C Tracy 836-M <br />Applicant - Return all copies to. Environmiantal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 91=1 <br />this <br />I -RI. <br />