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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ` .r -'1601 E. HAZELTON AVE., STOCKTON, CA <br /> - Telephone (209) 466-6751 -- <br /> r <br /> PERMIT EXPIRES,_J' YEAR-FROM DATE ISSUED <br /> tk herein <br /> v , r (Complete in Triplicate) <br /> y <br /> l <br /> t to <br /> Application is hereby made to the County <br /> O d calHealth .nce No.549 for sewage o'r District for a INo 1862 for wellTpump lor and tall he Ruoles.and Regulations of the San. This Joaquin <br /> made in compliance with San JoaquinN <br /> Local Health District. <br /> 'rsi�2 CeC <br /> Lot Size �M <br /> ity �eaOt f i' 's <br /> Job Address ' , <br /> t /Vv / e _ Phone <br /> Owner's Name ��Q��- -p�S�—� ' Address (l _ <br /> Address License No,_ -1—Phan _ <br /> Contractor DESTRUCTION ❑ <br /> NEW WELL ❑ WELL REPLACEMENT ❑ R.s <br /> TYPE OF WELLIPUMV. OTHER <br /> - PUMP INSTALLATION ❑ SYSTEM REPAIR D <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> *' FOUNDATION -- AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> { <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE <br /> o Dia. o i ' <br /> D Industrial fl Open Bottom L1 Manteca Dia. of Well Excavation Specifications <br /> Type of Casing - ` <br /> ��,.±.Domestic/Priv_ate El Gravel Pack C7 Tracy t T e of Grou -` - <br /> [-1 Othgr G - <br /> l Delta Depth of Grout Seal yp <br /> I I`1 Public ti - <br /> I Irrigation � pprox. Depth I I Eastern Surface Seal Installed by <br /> r e of Pum i H.P. State Work Done= �` <br /> i Repair Work Done U,- Type p <br /> Well Destruction L] Well Diameter Sealing Material (top 50') <br /> Depth ✓ Filler Material {Below 50'1 <br /> "TYPE OF SEPT ORK: NEW INSTALLATION [. REPAIRlADDITION I i DESTRUCTION I I (No Septic Sys em in 200 permitted if-public sewer is <br /> Installation will serve: Re - nce Commercial— Other _ <br /> Number of living units: her of bedrooms <br /> Wat depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC-TANKDisposal <br /> _` © Type/M1 Capacity, '- <br /> � Method of Dispo�l h� <br /> PKG. TREATMENT PLT_0 oaf Property Line Zc9t� <br /> - Distance to nearest: Well oundation- <br /> -. , <br /> ` 3 Total lengthtsize 2 O <br /> LEACHING LINE L4No. & Len Ines ' <br /> FILTER BED ❑ Dis a to nearest: WellFoundation Property tine <br /> I SEEPAGE PITS { I bepth.- Size _ Number <br /> SUMPS C1 Distance to nearest: Well Foundation Property Line P <br /> DISPOSAL PONDS ❑ <br /> is application I hereby certify that I have prepared thplication 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 /> y that in the performance of the work for which this permit is issued, I shall <br /> Home owner or licensed agent's signature certifies the following: "1 certif <br /> ' employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signaturi <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 compenF <br /> f <br /> tion laws of California." , <br /> ( <br /> The applicant m call for all requiredpections. Complete drawing on reverse side. r <br /> _ <br /> Title: Date: <br /> Signed X _ <br /> FOR DEP TMENT E ONLY <br /> Area f" <br /> t Application Accepted by date <br /> Date Final Inspection by L Date ' <br /> --Pit or Grout Inspection by I / r <br /> 97 �w'� <br /> Additional Comments: S <br /> E„ "t ❑ Stk A66-6781 O Lodi 369-3621 - Manteca 823-71 ❑ Tracy 835-6385 <br /> 4 . <br /> licant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O., Box 2009, Stk., CA 95201 <br /> r <br /> 'FEE., CK RECEIVED BY DATE PERMIT'NO.!_ <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> �o 2yGI /f 7 rxL] <br /> 1�r <br /> ♦ EH 1324(REV.1 i H 51 <br /> +, <br /> EH 14-26 ... . v 4 <br />