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.�, .. 4 <br /> ' H APPLIGAT N-k-FOR;..PERMIT <br /> SAN J0AQUIW.1L0CAL.HEALTH DISTRICT <br /> 1601 E.,HAZELT ON AVE., STOCKTON, CA <br /> I Telephone (209) 466-678 1 n , <br /> PERMIT EXP1R5 EAR.FROM DATt= ISSUED <br /> (Complete,in Trjplicate);,ce i r ti., .­144 1 <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'compliance'with•San,'J,oaquin County Ordinance No Ma for seviagworNo.;1862 for.welllpump and the Rules and Regulations of the'San Joaquin <br /> - - QOLocal Health District.. ~�l � -'`i a <br /> . x„*f4� 'f + s Y ti+ <br /> r : <br /> II j�.:;rn r 1t"' t4" ,fi C71L i+f fii to ,,.4:' , .til I' , J. ars ''t •r . <br /> Job Address �P - - �lty , Lot Size PM <br /> w <br /> L _ _ -. <br /> Owners Name GO Address _ Phone <br /> PhonAr� <br /> Contractor's Name License No. <br /> -TYPE OF WELL/PUMP: -" J NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION"k' SYSTEM REPAIR-O' OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL' OTHER WELL— PITS/SUMPS <br /> INTENDED USE, iTYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> �❑ Industrial ❑ Open Bottom ❑Manteca Dia. of Well Excavation Dia. of Well Casing <br /> )(Domestic/Private 11:1 Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public E] Other 1_73 Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation -!L-Approxi Depth ❑ Eastern 'Surface Seal Installed by <br /> Repair Work Done Ll Type of Pump H.P. i State Work Done <br /> ,Well Destruction -< ❑ Wall Diameter Sealing Material (top 50 <br /> { ., - Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR Ll DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> a <br /> . _...,_ g available within 200 feet. <br /> Installation will serve: ReIdence Commercial Other \ <br /> Number of living units: i�p Number of bedrooms <br /> Character of soil to a deptii�of 3 feet:' - Water table depth <br /> SEPTIC TANK ❑ I Type/Mfg Capacity. No. Compartments <br /> PKGr. TREATMENT.PLT.❑ I Method of Disposal <br /> r Distance to nearest:. <br /> Well Foundation Property Line <br /> Total len th/size <br /> LEACHING LINE ❑ No. & Length of lines 9 <br /> FILTER BED © � Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth j 'Size Number <br /> "SUMPS ❑ 'Distance to nearest:- 'Well _ Foundation Property Line <br /> k DISPOSAL PONDSr ❑ r� <br /> hereby certify that Ihave prepared this application and that the work-will be done in accordance with San Joaquin county,ordinances, state laws, and <br /> rules and•regulat!ona.of the tan Joaquin Local Health District' a - <br /> Home owner or licensed agent's signature certifies the following:IN 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.” Contractors 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 shatl employ persons subject to workman's compensa <br /> .. .:-tion laws of California. 0. ^ +- 4. <br /> i <br /> i The applicant or I,required i+nsFections. Complete drawing on revers ide.y <br /> iN. Title: Date: <br /> Signed <br /> FOR DEPARTMENT:USE ONLY <br /> Application Accepted by II` Date Area -f <br /> Pit or Grout Inspection l y Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 - -3 Lodi 369-3621 O Manteca 823-7104 - Tracy" 8355-6385 <br /> i Applicant- Return all copies to: Environmental Health Permit/Services 1601 Hazelton Ave., P.O. Box 2009,_Stk., CA 95201 <br /> -FEE AMOUNT'-'YAMOUNT DUE F AMOUNT REMITTED CK RECEIVED 8Y DATE PERMIT"N0. <br /> INFO n CASH <br /> + EH] -24 IREY.101831 i f � � '� , <br /> EH 14-28 - <br />