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APPLICATION FOR PERMIT <br /> SAN JOAQUIN"LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL TON AVE., STOCKTON, CA i Ih <br /> Telephoiine (209) 466-6791 71 49 4-t <br /> PERMIT EXPIRES'1':YEARFROM DATE ISSUIE_D <br /> (Cbrnpl eielrijri pkaW.1, <br /> z rain described.This application is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work he <br /> made in compliance with San Joaquin County Ordinance No.549.for'sewage or No. 1862 fo,r well pump and the Ryles and Regulations of the San Joaquin <br /> -Local'Health District. <br /> y4%, <br /> - 13i rl�Iyy Size PM <br /> Job Address <br /> Phone-Owner's Name 'Address P <br /> License No. <br /> 4� Phone <br /> Contractor: Address 9 - <br /> PUMP INSTALLATIO � <br /> NEW WELL ❑El WELL REPLACEMENT El El DESTRUCTION LI <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR OTHER 11 <br /> DISTANCEITO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.— PROP. LINE <br /> FOUNDATION AGRICULTURE WELL __ OTHER WELL PITS/SUMPS <br /> ,INTENDED USE TYPE OF WELL -PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industriai i 0 Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing <br /> omestic/Private El Gravel Pack 0 Tracy Type of Casing Specifications. <br /> L1 Public 0 Other 0 Delta. -Depth of Grout Sea] Type of Grout <br /> 0 Irrigation --Approx. Depth 0 Eastern Surface Seal Installed by— <br /> . . 1�V 16 � H.P. State Work.Done <br /> LI <br /> Repair Work Done Type of Pump <br /> Well Destru.btion $k_ Well Diameter b--7— Sealing IVISterial (top 501 <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION E] (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial Other 04 <br /> Number of living units: Number'of bedrooms <br /> Water table depth LA <br /> Character�o�soil to a depth of 3 feet: <br /> Capacity— No. Compartments <br /> SEPTIC TANK Ll Type/Mfg <br /> PKG. TREATMENT PLT�E Method of Disposal <br /> �,Distance to nearest: well—.Foundation Property Line <br /> Total len g <br /> FILTER BED th/siz <br /> LEACHING LINE r-N�.t9�Length of i lines sss <br /> C..LQ�tance to nearest: Well Foundation Property Line <br /> 4Number <br /> L <br /> SEEPAGE PIT6 Depth Size <br /> SUMPS D Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS E 4 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county&dinances, state laws, and <br /> rules and re6diations of the San JoaquinUcal Health District. permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I certify that'in the peRormance of the work for which this <br /> employ any'person in such manner as to become subject to workman'i compensation laws of California."Contractor's hiring or sub-contracting signature <br /> ;F certifies the following:"I certify that in th.e performance of the work for which this permit is issued, I shdll employ persons subject to workman's compensa <br /> tion laws of;C61ifornia. <br /> The applicant'must call for all required inspections. Complete drawing on reverse side. <br /> Date: <br /> S�01 e: DtTitle: <br /> Y� <br /> Signed Xl <br /> FOR DEPARTMENT USE ONLY <br /> A <br /> Application Accepted by Datd' rea <br /> at <br /> Pit o fe irial Inspe t /V Date t <br /> 'r Grout itilspeciion by WFI :)yi— <br /> to, -50 <br /> Additional Comments:_4_L� a 6,n nyl 0 d, <br /> [V§Tk Lodi 369-3621 1-1 Manteca 0 7 — Mant823-7104 ❑ Tracy 835-6385 0- Cc.pc,, <br /> iI <br /> pplicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9520 <br /> (Ve <br /> NO. <br /> FEE AMOUNT DUE -AMOUNT REMITTED CCK#-) RECEIVED By DATE -PERMIT ffF <br /> INFO <br /> IN=,211 <br /> ;+ EH 13-24 VkV, <br /> EH 14-25 <br />