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t.. T .�. <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 /> th District for a /or install the work <br /> . This <br /> cation is <br /> Applicaticonis heieby <br /> w made <br /> San Joaqu n County OLocalnWs No 549 for sewage or ealpermit <br /> 1882 forCwell/dpump and the Rules and herein <br /> Regulations of he San l Joaquin <br /> made n P I I <br /> Local Health District. <br /> r <br /> QQ City Lot Siz"INL61�c � PM <br /> Job Address <br /> Phone <br /> 000b 13a� to - 33-77 <br /> Address <br /> Owner's Name �7 f( ✓ <br /> n _a �, License N Z ` Phon <br /> Contract04'1�kddress <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑er DESTRUCTION EJ x <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ -OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE , <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing Specifications <br /> ❑ Domestic/Private 0 Gravel Pack ❑ Tracy yp T e of Grout <br /> [I Public Fl Other n Delta Depth of Grout Seal yp <br />' I I irrigation Approx. Depth l I Eastern <br /> Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump <br /> H,P: State Work Done _ - -- - <br /> Well Destruction ❑ Well Diameter Sealing Material Itop�50'1 s O <br /> Filler Material lo'w 50'°l- <br /> Depth <br /> WORK:—NEW.1NSTALLATION REP-AIR/ADDITI0N.1 1. DESTRUCTION..I-IrlNo.se eti thin 200 feet")ed.if,puhlicsewer is...r-..- 0 <br />[ TYPE-OF SEPTIC �} availab <br /> f �. � 1'r <br />+ l <br /> Installation will serve: Residence 2K- Commercial r Other <br /> Number of living units:•; Number of b rooms -K f ! <br /> .k1 1�,y, .-4; Water table depth <br /> Character of sod`to'a�depth of'3'feet: <br /> SEPTIC TANK Type/Mfg <br /> Capacity No,Compartments <br /> f er <br /> Method of Disposal <br /> PKG. TREATMENT PLT. C] <br /> Distance to nearest: 'R., <br /> ell <br /> WFoundation Property Line <br /> LEACHING LINE No. & Length of lines '"' Total length/size <br /> ' FILTER BED ❑ Distance to:nearest: Well 106 Foundation; Property Line <br /> i 1 !I <br /> Size =�V' -Numbar <br /> SEEPAGE PITS depth <br /> SUMPS Foundation Property Line <br /> Ll Di n e to near st: W _-[i -- <br /> DISPOSAL PONDS ❑ <br /> ' I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> e work for which this permit is issued, 1 shall not <br /> rules and regulations of the San Joaquin Local Health District. tied <br /> T Home owner or licensed agent's signature certifies the following: "I certify that in the performance of th <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 /> I 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 /> x tion laws of California." <br /> f The applicant u call for req 'red inspections. Complete drawing on revers! . C. <br /> f Title: Date: <br /> Signed X <br /> FOR DEPARTMENT USE ONLY C� <br /> r/ Area <br /> . �� Date <br /> Application Accepted by <br /> �If/Grout Inspection toy I <br /> Date{ Final Inspection by Dat <br /> dr tonalments: y <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 'tS*tt,,, <br /> / <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> r <br /> ffFECK RECEIVED BY DATE PERMIT'NO. <br /> INFAMOUNEDOEEAMOUNT REMITTED CASH <br /> •.EH 1321(REV.I/H 5) <br /> EH U-26 <br />