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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 /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> . This <br /> cation is <br /> n desc <br /> Application is heieb with Sano <br /> oJthe oaqu n Counqty Ordinalnce No.549 for sewage oriNo. 1862 forcwell//pump and the Rules and Health District for a permt to construt and/or install the work (Regulations of he Sans Joaquin <br /> made in compliance <br /> Local Health District. p{� <br /> ��,Se a 1e.D City Lot Size PM <br /> Job Address 1 <br /> �v n?G �"� �' ���%/� Phone <br /> Owner's Name '- � L�t/+��7/L1�1`r� Address �t e� v Ph <br /> Contractor " <br /> .pddress dJ. IvlJC.At License Nov�r/!:C5-- <br /> Phone <br /> TYPEOF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR El OTHER <br /> SEWER LINES DISPOSAL FLD. � PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> l,. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION Iia. of Well Casing <br /> ❑ Industrial El Open Bottom El Manteca Dia. of Well Excavation 1 SPecificatigns <br /> Type of Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Depth of Grout Seal Type of Grout -- <br /> iI Public -LT Other n Delta f <br /> I I Irrigation _.-Approx. Depth t 1 Easters) Surface Seal Installed by' <br /> State Work Done <br /> Repair Work Done ❑ Type of Pump H.P. — <br /> g Material (top*) <br /> Well Destruction ❑ Well Diameter Sealing - , <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION I I (Nailabptic hit system rmiitted if public sewer is <br /> avl�Installation will serve: Residence/commercial_ Other f� <br /> Number of living units: — Number,of bedrooms Water table depth ` <br /> Character of soil'to a depthof3 feet: o, partments <br /> SEPTIC TANK ❑ Type/Mfg Capacity_44C10—$Nflet od of Disposal <br /> PKG. TREATMENT PLT. ❑ _ Pr y 1pe _ <br /> Distance to nearest: el #7 Founde"tion <br /> LEACHING LINE No. &Length of �lines • Total length/si e � <br /> i�r*�N <br /> FILTER BED ❑ Distance td nearest: well �� I undation Prop ite + <br /> - r <br /> Size Number <br /> SEEPAGE PITS I I Depth property Line <br /> SUMPS Cl 'Distance t Qmt'"'w0 Foundation <br /> r <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared this application and that th orlill be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of-the Sarr Joaquin MNI 1 ct. 1 +/ work for <br /> Home owner or licensed agent's nna gas torbecome subject Ito w'o9rNRra oythat in the mpensation Iw sormance of of California." Contaotowr's'hir ng'or sub-contracting lsignlatuore <br /> employ any person irvsttc <br /> certifies the following: "I certify that in the performance of the vfich this permit is issued,I shall employ persons subject to workman's compensa <br /> tion laws of Califotnia." <br /> The applicant must call for all re din coons. Complete drawing on reverse side. A to <br /> Signed X <br /> .l• ��1,,,� Title: 2Date: <br /> DEPARTMENT USE <br /> Date • (/ Area <br /> ApplicationAccepted'by <br /> Date <br /> Final Inspection by Date <br /> Pit or Grout Inspection by <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy, 835-6385 <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton'Ave., P.O. Box 2009, Stk., CA 95201 <br /> ffFE4C9ASH !!!Y DATE PERMIT NO. <br /> FAMOUNTDEUE REMITTED <br /> ♦.EH 13.24(REV.1 N 5) <br /> EH 14-26 <br />