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APPLICATIO_{ .FOR PERMIT <br /> SAN JOAQUIN*LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON-AVE., STOCKTON, CA <br /> Telephone (209) 466-6781' <br /> ��, �.i.. rf 'n tt:t t�, tfi ft $Oi�O� DC7 2f @sfm to na ngo ,1 <br /> PERMIT EXPIRES,1 YEAR FROM DATE-ISSUED .w6�, fiy el 10 <br /> 2 h r r :"s ,• , r ! o. T;; 3 .r. {Complete.in Triplicate}.rbc i ;'ozma! 1owi3?ucienl <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install,the work herein described"This application is <br /> made in,compiiance with.San-Joaquin for sewage 1 r,No.,Ia62lfiorwell/.Pump.and the,Rules and Regulations of the San Joaquin <br /> Local Health Dlstrict,��,, $ F ti.q,4 `§i lx 't ls;l*n y.;f4 tG .rte f# V 4Q;K F;c.i 7 )a ' to noiP ir-gx3 be <br /> to noil3 D <br /> City ' ,Lo#Size . PM <br /> Job Address 7701. N. <br /> 1'0.41;lkfioFlj I)3 Ve "-r tOCkt4Y}"Phone W 1= b2 <br /> " {y31iw�'dT1FlEte�.p ; `AddrBss� ' <br /> w_ a <br /> Owner's Name � _. --•-�- —� �.-_.-�,,...--�:,.- <br /> -ry &782' CI SS C-21 Phone <br /> Contfactor's Name , J@7G7CY & Ba7'b ; t DBense Na _ r <br />' Y TYPE OF WELLIPUMP: i NEW WELL. El " -1 WELLAEPLACEMENT 11DESTRUCTION ❑. # r <br /> r `-PUMP INSTALLATION. ❑ ,SYSTEM REPAIR © OTHER'D k s "'►" k <br /> DISTANCE TO NEAREST: SEPTIC TANK, t SEWER LINES ; . DISPOSAL FLD. ti PROP LIME <br /> EPITS/SUmm, <br /> FOUNDATION AGRICULTURE WELL OTHER WELL' - <br /> :. ,. <br /> z <br /> INTENDED USE TYPE OF WELL; PR09LEM AREA CONSTRUCTION SPECIFICATIONS r 1 <br /> ` F Open. - - ❑ Manteca- <br /> Dia. W6II Excavation -Dia. of Well Casing , <br /> Industrial- ❑ Ope Specifications <br /> ❑ Domestic/Private El Gravel Pack Tracy Type of Casing <br /> Grout <br /> ❑ Public <br /> -❑ Other p Delta Depth of Grout Sea! "type of d <br /> '❑ Irrigation —M; _�Approx. Depth <br /> El Eastern Surface Seal Installed by <br /> Repair Work Done p Type of'Pump H.P. 8 State Work Done <br /> I 11 -w <br /> ..fe.. f - f' 7 <br /> Well Destruction ❑ Well Diameter* Sealing Material atop 50 1 . <br /> 9 - Depth - Filler Material {Below 50') i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ xREPAIR/ADDITION 1:3DESTRUCTION)MINo septic system.permitted if public sewer is <br /> -..� _.- .. - w available within 200,feet.l <br /> Installation+WWII serve:-,,Residence Commercial Other <br /> k. _ '% <br /> Number of living un-its: Number of bedrooms <br /> ;�- . Water table de�ith" <br /> t Character of soil to a depth of 3 feet: <br /> ,., ' Capacity 'No: Compartments }� <br /> SEPTIC TANK: ❑ Type/Mfg ? <br /> ,} ,ya �'' �' Method of Disposal O� <br /> PKG. TREATMENT PLT.![] <br /> f Distance to nearest:' Wella Foundation Property Line <br /> ' :. <br /> LEACHING LINE -t s ❑ No. &1Length of lines Total length/size <br /> .. ;, .P n Property Line :' ` <br /> I FILTER BED ❑ Distance'to nearest. Well r Foundation t <br /> SEEPAGE,PITS ' ❑ Depth, t Size Number <br /> I- SUMPS 1 t ❑��"SDistance to nearest: I- "Well Y i h Foundation Property Line f <br /> DISPOSAL PONDS ❑ <br /> k 1 hereby cert!fy'that l have prepared this application and that the'work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulation's of the San Joaquin Local Health District. W <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,,1 shall not <br /> employ any person in such manner as to:become subject to workman's compensation laws of California."Contractors hiring c 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 ornia." <br /> The applicant cal"for all i i pectians. Complete drawing on reverse side: ri r I <br /> !�' <br /> r , �,� r • flwne"r -28-85 <br /> Date: <br /> rSigned tiT Title: - t 4 <br /> I MR DEPARTMENT-USE ONLY Area <br /> i # __ -. . . .. ��'- <br /> =- - i r�. ! <br /> Application Accepted by Date <br /> t ' Final Inspection by Date <br /> Date <br /> 12 <br /> Tip <br /> I ; <br /> Pit or Grout Inspection by I( .. <br /> ' - ., -. <br /> krAi,!tional CommentCom . 0 LodiManteca 823 7104 ❑ Tracy -835 6385Applicant:- Return all copies to <br /> Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i } - AMOUNT pUE AMOUNT REMITTED JED BYCASHRECEIV ..DATE PERMIT'NO: <br /> :-FEE- <br /> NFO <br /> �s , -s S 7 s <br /> +�EH 13-24'REV.141631 <br /> EH W26 - - - - - - - - . <br />