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-* APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA 1 , <br /> Telephone (209) 466-6781 � AL'LH• <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED VwVr� \.)- I jS�RV10ES <br /> {Complete in Triplicate} <br /> Appicaton is t and/or install the work <br /> ation is <br /> madle inl compliance writh Sano <br /> oJoaquin County O d nathe$an Joaquin Localnc{e No.549 for sewage or ealth District for a 1No, 1862 for t to cwell pump and the Rules and IR Regulations of the SanJoaquin <br /> Local Health District. <br /> City Lot Size a/— PM <br /> s Job Address `f[ilio � 07,96 <br /> Owner's Name — <br /> ` /(1 Ie� ddress Phone <br /> t GrA1;v7Z)2. ���/ <br /> /}/)fj/�J9111 S SSS Address License No. O A [�Phone <br /> Contractor <br /> i TYPE OF WELL/PUMP: NEW W.ELL;❑ EL_L`-,REPLACEMENT' CJ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ .1 SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> - DISPOSAL FLD. PROP, LINE <br /> FOUNDATION_ AGRICULTURE WELL OTHER WELL SU <br /> �_PITSIMPS ---- <br /> kNTENOFd"USE STYPE OF WEiL=-PROBLEMAREA- CONSTROCTION-SPECIFICATIONS:""-Y Dia. of WellCasing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> Domestic/Private ❑ Gravel Pack Ll Tracy -Type of Casing <br /> II I Ll Delta Depth of Grout Seal Type of Grout <br /> ('1 Cl Other Public I i _ <br /> I I Irrigation Appfox. Depth I I Eastern S,urjace Seal Installed by ` <br /> ` State Work Done t r� <br /> Repair Work Done ❑ Type of Pump - H.P. c <br /> ` i Sealing Material Ito 50'1 <br /> Well Destruction ❑ Well Diameter g p <br /> Depth { I Filler Material (Below 501 <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION I.1 REPAIR/ADDITION l I DESTRUCTION l 1 INO <br /> ave septic system permitted if public sewer is <br /> F ' available within 200 feet.) G <br /> ( installation will serve. Residence$ Comimercial_ Other S <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:_ ^y Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal } <br /> Distance to nearest: Well Foundation Pro6erty.Line <br /> s <br /> ` <br /> LEACHING LINE ❑ No. & Length' Total length/size of lines_ __ _ •__ <br /> 1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line i <br /> SEEPAGE PITS ['I Depth 1 Si a ` ' 4 Number <br /> SUMPS Ll Distance to nearest: Well [Foundation Property Line <br /> DISPOSAL PONDS S ❑ ""'�` -. ._.^�...,... F �.._ , ,_._� � .:�;w-.:.�,-��� =� •y,•-- �,. <br /> I hereby certify that I have preparedthis application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> l_ t I. <br /> I rules and regulations of the San Joagluin Locab Health District. r4.t , 4, <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work far 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 fiinng-or sub contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, k shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicantrequir tions. Complete drawing on revers ide. <br /> Signed X Title: <br /> W, 4��, — Date: <br /> 1 <br /> _ FOR DEPARTMENT USE ONLY � l <br /> - <br /> � Area . (� <br /> Application Accepted by Date J <br /> Pit or Grout Inspection by <br /> Date ,Final Inspection by pate � ' <br /> i <br /> Additional Comments: <br /> ❑-Stk 466-6781 © Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 6365 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601.E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> j INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> 4 +.EH13-241REV 1/851 <br /> EH 14-26 �� -�� <br />