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s13�� <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 EHAZE.TEON-"AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 . CEIVEW <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) DEC 6 1999 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instEINVAO WAtqu, kation is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the ry I �nv <br /> Joaquin <br /> Local health District. �i J <br /> Job AddreCit of Size PM <br /> Owner's�Nafne," r C-d ns ISG[ dodressA 'we-M- _ Phone r <br /> y rs <br /> Contra or Lv.- Addressf� d l r Z 7 License No./62,3Phone_ �. ar/ <br /> TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT ❑ DESTRUCTION [1) <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ✓ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> )�t) h},OION AGRICULTURE WELL - OTHER WELL PITS/SUMPSJFU <br /> - -- - s. <br /> INTENDED USE i TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> r <br /> ❑ Domestic/Private ❑ Gravel"Pack ❑ Tracy Type of Casing Specifications l .> <br /> F] Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout ' <br /> I I Irrigation Approx. Depw, l I 'stern Surface Seal Installed-by I _ <br /> r v _ <br /> Repair Work Done Cl�Type of P{ump 19:P. /. r } '+State Work one_ t <br /> Well Destruction ❑ Well Dia —Sealing.Material-[top50')_.-- <br /> beptfi- Filler MateriaObelow 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l'I Ftfi'AIR/ADDITION I I `DESTRUCTION"I-l'(No septic system permitted if public sewer is W <br /> } �, available within 200 feet,) , ) <br /> Installation will serve:. Residence 1 Commercial Other _ 1 <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK El Type/ <br /> Mfg - =- -Capacity w-� t No. Compartments I <br /> PKG. TREATMENT PLT. ❑ i Method of Disposal <br /> h. 7 I <br /> Distance to nearest: Well' Foundaflon ` - Property Line <br /> LEACHING LINE ❑ No. & Length of lines j -. 1;otaI 1 rtgth/size <br /> FILTER BED ❑ Distance to nearest: d Well Founda[i n �'t i' jProperty Line <br /> N <br /> SEEPAGE PITS I ! Depth :' s Size - Ir .\`', Number r ' <br /> SUMPS L� Distance to nearest: +Well _ Foundation V ` 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 oVnin <br /> enYs signature certifies the fallowing: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ such nner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies "I cart that 1the rforman f the work for which this permit is issued, f shall employ persons subject to workman's compensa- <br /> tion law ."The appall re r,a Cam to drawing on r r e. ' <br /> Ace <br /> Signed Title: Date: /O Zl <br /> F DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> i <br /> Pit or Grout Inspection by Dice Final Inspection by Date Z� <br /> Additional Comments: / <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 <br /> CK ff <br /> INFO FEE AMOUNT DUE AMOUNT.REMITTED CASH RECEIVED 8Y DATE PERMI-r NO. <br /> EH 13-24 1Rev.r i a 51 ! �} <br /> EH t4-26 ��A <br />