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APPLICATION FOR PERMIT Alv <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �j <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> i (Complete in Triplicate) <br /> I .In Local Health District for a <br /> Application sheiewith a to the San <br /> n Joaqui ry Ordinance No.549 for sewage or permit <br /> 1862 for cwell/pump and the Rules and[Regulations of the Sans Joaquin <br /> made incompliance <br /> Local Health District. O p� y <br /> I� f f � Ir6 � - -� City G� Lot Size �`! �11 PM <br /> Job Address (� oy <br /> 39i hone Z 3 <br /> Owner'sName � � LI Address <br /> , <br /> f f <br /> Contractor u <br /> inp <br /> Address 4 License No. Phone 'r <br /> TYPE OF WELL/PUMP: NEW WELL C* WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION 4, SYSTEM REPAIR ElOTHER 1-1DISTANCE TO NEAREST: SEPTIC TANK 1_4a.—rSEIVER LINES �Da + DISPOSAL FLD. PROP. LINE Zbl L <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL /PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Manteca Dia. of Well Excavation <br /> ❑ Industrial ❑ Open Bottom Dia. of Well Casing <br /> Specifications <br /> Type of Casing <br /> +Domestic I Private I,Cravel Pack,. ❑ Tracy, r <br /> _ `-F7 Delta '. Depth of Grout Seal Type of Grout <br /> M`1 P <br /> ublic <br /> n Other Q <br /> I Irrigation (a Apprfol Depth I Eastern "Surface Seal Installed by - �r <br /> Repair Work Done LlType of Pump H.P. ` State Work'Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth 4�-,. - 'Filler Material ('Below 50') -� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION ! I (No septic system permitted if publi ,'sewer is <br /> available within 200 feet.) <br /> 1 <br /> I, installation will serve: Residence— Commercial_ Other <br /> k � <br /> s Number of living units: Number'of bedrooms <br /> V Water table depth 't <br /> Character of soil to a depth of 3 feet: ,, <br /> t SEPTIC TANK L) Type/Mfgi Capacity No. Compartments <br /> l Method of Disposal <br /> E PKG, TREATMENT PLT. El t, t I !r <br /> Distance to nearest: Well r Foundation Property Line �} <br /> f c� <br /> f LEACHING LINE ❑ No. &-Length of lines- ''�� Total length/size <br /> FILTER BED ❑ Distance..to neaWell _ "t' Foundation Property Line <br /> SEEPAGE PITS l I Depth f Size t� — Number <br /> SUMPS ❑ 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 certifiesthe following: "I certify that in the performance of the work for which this permit is issued, I shall not <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." ! r <br /> i The applican st call for all re ed ins t ions, Complete rawing-on-reveise_side. <br /> r Signed X Title: Date: , <br /> + 5 '•,�- �`. FO. DE RTMENT USE ONLYq � �-- <br /> CApplication Accepted by 1 - Date c/7 a <br /> Pit o G ut nspection by <br /> pate Final Inspection by Date�� <br /> 4 Additional Comments: <br /> € ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 836-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20W, Stk., CA 95201 <br /> I ? IFEENFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. <br /> -2 13S <br /> +.EH-13-14 IREV.1/"5)W 9'Y O t� 3 <br /> EH 14-26 <br /> 13y,o0 <br />