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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> SCANTED <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> . This <br /> cation is <br /> made in <br /> Application <br /> ance with Sanade othe San)Joaquin Counguin ty Ordinance llNth District for a o.549 for sewage or permit <br /> No. 1862 for constructand/or <br /> and the Rules and herein <br /> R Regulations of the Sans Joaquin <br /> Local Health District. <br /> Job Address <br /> 17345 E. Hwy 88, Ci Lot Size PM <br /> Robert Sutter 1640 Edgewood Drive, Lodi Phone <br /> Owner's Name Address <br /> Contractor ��dr <br /> Purviance Driller jLicense No.' Phone <br /> nc. ,POBox- 64,Linde 377923 887-3554 <br /> TYPE OF WELL/PUMP: NEW WELL 9 WELL REPLACEMENT ❑ DESTRUCTION ❑ { <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> w <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 16" <br /> ❑ Industria! C1 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 250 <br /> ❑ Domestic/Private ❑ Gravel Pack El Tracy Type of Casing steel Specifications <br /> I'1 Public <br /> Cl Other ❑ Delta Depth of Grout Seal 50 Type of Grout Cement _ <br /> XI Irrigation 6501Approx. Depth l I Eastern Surface Sea! Installed by - <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') — <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 1 DESTRUCTION I I INo septic system <br /> m permitted if public sewer is <br /> avaInstallation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> rA SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments �{-+ <br /> PKG. TREATMENT PLT. 0 Method of Disposal r <br /> Distance to nearest: Well r Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I l Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance vyith San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health Di§trict. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for 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 hiring or sub-contracting signature <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 compensa- <br /> tion laws of California." <br /> The ap can ust c 11 f all a wire inspections. Complete drawing on reverse side. <br /> President 1/8/90 <br /> Signed X 1' `L;TitEe: Date: <br /> FOR DEPARTMENT USE ONLY A <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments:T <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Ma teca 823-7104 ❑ Tracy -6385 <br /> Applicant- Return ail copies to: Envir nfne�tal HePermit/Servicesj-1/6�41 E. Hazelton P.O. Box 2009, Stk., A 9 01f- <br /> FEE AMOUNT DUE AMOUNT REMITTED CK 9 CASH RECEIVED BY DATE PERMIT�NO. / <br /> INFO <br /> +.EH13-24(REV,I R5) <br /> t EH 14-26 <br />