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r APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Ith District for a to construt and/or install the workdeSCFibe , This <br /> Application is hereby made t the SJoaquin Local Hea <br /> n County ordinance No.549 for sewage or permit 1862 for well/pump and the Rules and'Regulationis <br /> s of the Sang cation Joaquin <br /> made in compliance w <br /> Local Health District. <br /> Job Address 17345 E. k[ 88, <br /> City at Size PM <br /> Robert Sutter Address"40 EdgeVOOd Driver Lodi Phone <br /> Owner's Name 837-3554 <br /> Purviance Dri11er *nP0B0X 64,Linde License No. 377923 Phone <br /> Contractor -- �dreS <br /> TYPE OF WELLJPUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES ^-- DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> a <br /> lb" <br /> Well Casing <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUC71 SPECIFICATIONS <br /> Al pia.of We <br /> ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well E� :avation .25© <br /> F1 Domestic I Private ❑ Gravel Pack ❑ Tracy Type of Casing $t�e1 Specifications <br /> t� Type of Grout C�eJ1t <br /> DI`} Public n Other n Delta Depth of Grout Segal,,,,` <br /> $I Irrigation �1Ap7of_epth 1 I Eastern Surfa e I In tallad�y��' r � - 15 <br /> H State Work Done_ <br /> Repair Work Done t_3TYPe f-P mp <br /> Well Destruction ❑ We Diam�ter S lin M to erial I p 50'1 <br /> D pth Fill atenal I low 50' / <br /> TYPE OF SEPTIC WORK: EW INS LLATION I I REPAIR/ ,DDITION ST UL;7ION I I (Nos ptiwthin m perErmined if public sewer is <br /> availaInstallation will serve: R sidence Com rcial Ot r <br /> Number of living units: Numb r of b rooms Water table depth <br /> Character of soil to a dep of 3 feet: <br /> Capac-y No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> stance to nearest: Well Foundati Property Line <br /> Total length/size <br /> LEACHING LINE ❑ No. & hof lines <br /> FILTER BED D Distance to nearest: Well Fou dation Property Line <br /> SEEPAGE PITS t I 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 n accordance with San Joaquin county ordinances, state laws, and <br /> k will be done i _,, <br /> rules and regulations of the San Joaquin Local Health Diltrict. <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 applicant'r�iust colt fq all reAuirro inspections. Complete drawing on reverse side. 1/8/90 <br /> I ;.�- FreeidOnt Date: <br /> Signed X <br /> fi ; 1 .( ;_. .e f Title: <br /> FOR DEPARTMENT USE ONLY Y <br /> -i.. <br /> Date _a <br /> /- Vii_ _ <br /> Application Accepted by "' =''�"'" '" <br /> Dated Final lnspection y' Dat$ <br /> Pit or rout nspection by <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Man t ca 104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9520/ <br /> CK <br /> FEE AM UNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> + EH 13.2 (REV.1/85) f.r-•. •.-•. _ ! � 1.;. <br /> Ers N-25 <br />