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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> L PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> t to <br /> t and/or install the work <br /> n describe . This <br /> cation is <br /> madlecntcompliance wiitth San ade oJoaquithe n County O d nauin Localnce No.549 for sewage orHealth District for a 'No. 1862 for cwell/pump and the Rules and'R gulations of the Sans Joaquin <br /> Local Health District. <br /> City — Lot Size PM y�'/ <br /> Job Addressr.-''�" /CSG <br /> i r la. Address ", ", �+ '� `j �y Phone <br /> Owner's Name SG� y�.4, <br /> 1S M-0 ,�1l )(QR(' License No.y /�Phoned 3M) <br /> Contractor Address <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION)V CWSYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE –TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> omestic/Private El Gravel Pack El Tracy Type of Casing <br /> FI Public F1 Other ❑ Delta Depth of Grout Seal <br /> Type of Grout <br /> I I Irrigation _..Approx. Depth <br /> I�I�Eastern Syrf ce Seal Installed by <br /> Repair Work Done ❑ Type of Pump <br /> 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 l l REPAIR/ADDITION l I DESTRUCTION I I alvailableseptic <br /> wthin 200 feet.) if public sewer is <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK El Type/Mfg Capacity No. Compartments <br /> Method of Disposal "7l� <br /> PKG. TREATMENT PLT. ❑ 1�' <br /> Distance to nearest: Well_ __ Foundation Property Line <br /> LEACHING LINE ElNo. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Prgperty Line <br /> `4 <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 Di§trict. <br /> Home owner or licensed agent's signature certifies the following: ' permit is issued, I shall not <br /> certify that in the performance of�the work for which this <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." <br /> The applicayst I requiresp . Complete drawing on reverse side. <br /> Signed X <br /> —itle: Date: <br /> *FOR DEPARTMENT USE ON Y J <br /> 02Application Accepted by Date <br /> ,r?s._�� Dat s' <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: <br /> 11 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 6385 ` <br /> Applicant- Return all copies to: Environmental Health Permit/Son ices 1601`E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEECK RECEIVED BY DATE PERMIT"NO. <br /> INFO AMnnOUNT DUE AMOUNT REMITTED CASH <br /> + EH13-24(REV.►/85) c7 S. C�. Or Dy <br /> EH 14-26 <br />