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a APPLICATION FOR PERMIT <br /> + ! SAN-JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTOWAVE'`, STOCKTON, CA <br /> ' Telephone 52091 x466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED it <br /> (Complete in Triplicate) JUL 9 18$ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the l�,�p rein described. This application is <br /> made in compliance with San Joaquin County Ordinance No. 549 far sewage or No. 1862 for well/pump and the i tal5ID"Ar 4 the San Joaquin <br /> Local Health District. , ERM17/SE/r1tRLLY10EEAL7H <br /> Job Address ' 0 City PM <br /> Owner's Name•44�� � Address VV - �►A/-fi t Phone <br /> p <br /> Contracto Address 1 21 License No./j�-3-.1-Phone <br /> TYPE OF WELLlPUMP: N W WELL Cl WELL REPLACEMENT ❑ DESTRUCTION 171 <br /> - PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> !INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications) <br /> fl Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout' <br /> I I Irrigation � ? - _.-Approx. Depth l I fastem Surface Seal Installed by !� <br /> Repair Work,pone r i�T�ype'of lPump sem- H.P. __ State Work Done <br /> Well�Destructiorr., ❑ Wei I Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50'1 '")�I <br /> r ` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION l 1 INo septic system permitted if public sewer is <br /> I t available within 200 feet.) " <br /> Installation will serve: Residence— Commercial_ Other <br /> r <br /> Numberlof living units: Number of bedrooms . rn <br /> Character of soil to a depth of 3 feet: Water table depth i <br /> SEPTIC TANK ❑ Type/Mfg Capacity 1l.i1 No. Compartments 1 <br /> PKGf'TRE ATMENT PLT. ❑ � "-Method of Disposal <br /> Distance to nearest: Well Foundation � Property Line`F ' <br /> LEACHING LINE D 'No!& Length of lines Total length/size ` ~ <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line IIVV„ <br /> V <br /> SEEPAGE;PITS I i Depth Size Number , .jJ� ; <br /> SUMPS L Distance to nearest: Well Foundation Property Line "1A � <br /> DISPOSAL PONDS ❑ <br /> I herr}by 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 /> Nome 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 /> employ any person in suc nner as to beco subja to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following cert,y that in the or a a f the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Callfo Ia.- <br /> The applicant ca r I req to (� a drawing onre side. <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 7--17 / ^- le-Area x'17 <br /> I c' - - 1_. <br /> Pit or Grout Inspection by Data Final Inspection by Date &31--XV <br /> Additional Comments: <br /> ❑ Silk 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 /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> +.EH 13-24(REV.t i a 5) �S• /��1 ' furl <br /> ! <br /> EH 14-28 <br />