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7� <br /> 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 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Applicat /or install the work <br /> n describe . <br /> is <br /> cation is <br /> made in(compliance with made <br /> SanoJoaqu nthe SanCounty Ordinance No. 549 for sewage or Joaq u1n LocHealth District for a permit <br /> No. 1862 forcwell/dpump and the Rules and IR gulations of(the San Joaquin <br /> Local Health District. l <br /> saw " "" City Lot Size � Q-� PM <br /> Job Address — ' <br /> Address t 'l Z i Phone <br /> Owner's Name <br /> ' �.�, License N0.32Z Phone3 6 r�,� <br /> Contracto ddresss5L, 4 <br /> E <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUGTION C] y <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE 4 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> ❑ industrial ❑ Open Bottom El Manteca Dia. of Well Excavation i <br /> Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> * Public Q Other [Z Delta Depth of Grout Seal Type of Grout — <br /> I i Irrigation --Approx. Depth l l Eastern Surface Seal installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 -- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION � REPAIR/ADDITION l 1 DESTRUCTION I') lNo septic system permitted if public sewer is ' <br /> available within 200 feet.] _ <br /> Installation will'serve: Residence Commercial ther / <br /> Number of living units: __/_ Number of rooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK � Type/Mfg � Capacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ ! { <br /> Distance to nearest: Well �Q Foundation_ tZ— Property Line.?,-:s-- <br /> 0— <br /> ine s <br /> 6 X2 <br /> LEACHING LINE No. & Length,of lines � !oral length/size <br /> FILTER BED ❑ Distance to near se t: Well— � - Foundation _.— Property Lin <br /> SEEPAGE PITS `4 Depth Jr Size_—T Numb <br /> SUMPS Li Distance Distance to nearest: well Foundation Property Line7i <br /> 4 DISPOSAL PONDS ❑ <br /> l I hereby certify that I have 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 San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: '"1 certify that in the performance of the work for which this`.permit is issued, i shah no <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." ° Ilk <br /> The applican m t call for . q d inspections. Complete drawing on reverse s'Ifie.(1 <br /> t i�j .{i-� Q <br /> Title: Date: <br /> Signed X <br /> -FOR DEPARTMENT-USE.ONLY".> } , •----�--�".a" �� <br /> Date �' .-Area, <br /> Application Accepted by <br /> r 1 a��, Date - �cl <br /> opit" <br /> Grout Inspection b Final lnspectian b., Data <br /> Additional Comments: — -- , <br /> Cl Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 7104 Q Tracy 835-6385 <br /> " <br /> Applicant - Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE CK RECEIVED BY DATE PERMIT NO. <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO / <br /> 4 ..EH13-21IREY.1iNs1 O0 DR ������ <br /> EH 14-26 <br /> t <br />