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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA VJH DISipN ` r <br /> Telephone {209) 466.6781 1 <br /> o�NttiA IH olv <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUE? %4 �� �� 1 <br /> (Complete in Triplicate? SN1,4 <br /> ����• <br /> I <br /> install herein described. This application is <br /> Application is hereby made to the San Joaquin Local Health District F f ago o't to No. 1862 farcweillPUP and the and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance <br /> Local Health District. <br /> /! <br /> City }P� Lot Si,, PM ; <br /> Job Address131511 . <br /> J0e o Phone <br /> Owner's Name '�f^t7- Address oX &7 <br /> 'Do-d oildl z <br /> �a�thD LIQ 4o <i" Phone 6 -E L <br /> ,8*T' :� i/1f�, Address 3�cs' Q"'+e - (_i r __License NO.Contractor DESTRUCTION C3 I <br /> TYPE Of WELLY PUMP' NEW WELL ❑ WELL REPLACEMENT ❑ <br /> SYSTEMA REPAIR ❑ OTHER 3 rri`f1VitP-V <br /> PUMP INSTALLATION ❑ <br /> L3SSTANCE TO NEAREST: SEPTIC TANK SEWER LINES �—� DISPOSAL FLD._ PROP. LINE �Z- <br /> FOUNDATION <br /> AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> WTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> (] industrial zg— <br /> ❑ Open Bottom © Manteca Dia. of Wail Excavation' C - specifications M4", <br /> ing C <br /> 0 Domestic/Private 19 Gravel Pack ❑ Tracy Type ofasType of Grout <br /> f I Other 11 Delta Depth of Grout Seaf <br /> C1 Public r <br /> I I Irrigation 4J2—Approx. Depth t I Eastern Surface Seal Installed by - <br /> Repair Work Done C3 Type of Pump -- H.P State Work Done <br /> Well Oostructicn ❑ Well Diameter y. -- sealing Material (top 501 <br /> ' <br /> 1 <br /> Filler Material (8610w w 50I <br /> Depth Fi er <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION I 1 pEPAIR/ADDITION 1.I DESTRUCTION I 1 availab etc system within 200 fast.)ed if public sewer is <br /> F 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: No. Compartments <br /> i SEPTIC TANK ❑ Type/Mfg Capaciry_��— U <br /> l Method of Disposal <br /> I PKG. TREATMENT PLT.❑ DiProperty Line <br /> ! - stance to nearest: Well Foundation <br /> f<. <br /> Total length/size ° <br /> LEACHING LINE ❑ No. & Length of lines property Line <br /> FILTER BED ❑ Distance to nearest: <br /> Well Foundation_�� <br /> Size_ Number <br /> f SEEPAGE PITS 11 Depth Property Line_ <br /> ik SUMPS 0 Distance to nearest: Well_ Foundation <br /> DISPOSAL PONDS ❑' <br /> t`E will be done in accordance with San Joaquin county ordinances. state laws. and <br /> I hereby certify that I have prepared this application and that the work <br /> 4 rules and regulations of the San Joaquin Local Health District. <br /> i 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 /> I <br /> compensation taws of California.,, <br /> employ any person in such manner as to become subject to workman's shall employ persons,ring or subject to wgdcma ting�Qs�i$gn <br /> certifies the following: -I certify that in the performance of the work for which this permit is issuedlicant must call fAN �OAQUIN LOLL HEALTH <br /> tion laws of California." HEALTH DIVISION <br /> The app ENVIRONMENTAL <br /> or all required inspections_ Complete drawing on reverse side. <br /> Title: <br /> Sign <br /> FOR DEPARTMENT USE ONLY <br /> r Date <br /> Application Accepted by �( <br /> pi �Gouspection bV <br /> Date Final inspection by Date v <br /> Additional Comments: <br /> 0 Stk -466-6781 ❑ Lodi 3&9-3fi21 ❑ Manteca 823-7104 ❑ Tracy 835 6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1501 E. Hazelton Ave., P.O. Box 2409. Stk.. CA 95201 <br /> K RECEIVED BY DATE PERMIT NO.. <br /> FEE pMOUN7 DUE AMOUNT REMITTED gN , <br /> INFO <br /> ..Et1 17-24 I REV.I I As co O <br /> EN t}28 <br />