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' APPLICATION FOR PERMIT <br /> SAN JOAQU1N LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ` (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a� work _ <br /> made in compliance with Sari'Joaquirt County Ordinance Na.549 for sewage Permit <br /> 1861 for well/pump the Rules and Reherein gulations of <br /> is <br /> Local Health District. - p p eg oaquin <br /> Job Address _- f <br /> —.City �N Lot Size PM <br /> Owner's Name -7IYUI /?SIT /(f1A1 VAlls���/}�i� �1�� <br /> �T Phone <br /> Contractor -�5 Address Z� VjJf,� <br /> �ieense Na.�_phone <br /> TYPE OF WELL/PUMP: i� NEW WELL .❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION REPAIR REPAIR ❑ OTHER O <br /> DISTANCE TO NEAREST: SEPTIC TANK LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Indusirial ❑ Open Bottom L7 Manteca Dia. of Well Excavation <br /> omestic/Private ❑ Gravel Pack Dia. of Well Casing _ <br /> ❑ Trac Specifications <br /> i Q Public � ❑ pelta d.« Type of Casing <br /> ❑ Other Depth of Grout Seal <br /> El Irrigations I Type of Grout <br /> h# pprox. Depth ❑ Eastern . Surface Seal Installed by <br /> Repair Work Done ❑ j Type of Pump _ H p _ p <br /> • t 1 State Work Done <br /> Well Destruction ❑ Well Diameter� 3U <br /> S Seating Material (top 50') �U Ae' <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ElDESTRUCTION ❑ (No septic p system permitted if public sewer is ' <br /> Installation will serve: Residence_ Commercial available within 200 feet.) a <br /> Ill <br /> Other <br /> Number of living units: Ill Number of bedrooms i <br /> Character of soil to a depth of 3 feet: j <br /> I.. r - Water table depth <br /> SEPTIC TAMC ❑ Type/Mfg i 4 <br /> { Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ i <br /> Method of Disposal <br /> eAlstance to nearest:- Well Foundation Property Line <br /> } . <br /> LEACHING LINE 0'7 o. & Length of lines i I <br /> FILTER BEDTotal length/size <br /> ❑, Distance to riearest: Well Foundation Property Line <br /> SEEPAGE PITS f❑ Diepth Size a Y <br /> El Number <br /> SUMPS 2❑ listance to nearest:"; well Foundation Property Line <br /> DISPOSAL PONDS I ' r❑ I` <br /> I hereby certify that I hada prepared this application and,that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the Sari Joaquin Local Health District: <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 y <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- 7 <br /> tion laws of California." ��. <br /> IIS <br /> The applicant m t ca far II requir i s ctions, Complete drawing on r ve side. <br /> g � s <br /> 5'r ned Title: _ Date: <br /> g FOR DEPARTMENT USE ONLY <br /> Application Accepted byI ? x_,/'741 <br /> Date�! 'ta Area <br /> Pit or Grout Inspection by I Date Final Inspection by <br /> Date <br /> Additional Comments: <br /> ❑-Stk---466-6781-_p-.Lodi; *-3621...».w O'Manteca-.823.7104-0-Tracy-835-6385, <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009r Stk., CA 95201 <br /> II! <br /> FEE , <br /> INFO AMOUNT DUE AMOUNT REMITTED ' 'GK y RECEIVED BYE <br /> I CASH DATE PERMIT NO, i <br /> + EH 1324(REV.v/a 5) j <br /> EH 14-28 // SI �+ -�Z�nCi <br /> b <br /> .I� yi <br />