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f APPLICATION FOR PERMIT <br /> _ SAN JOAQUIN LOCAL HEALTH DISTRICTD <br /> 1601 E. HAZETON AVE., STOCKTON, CA ' 6 1988 <br /> Telephone (209) 466-6781 OCT <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED nl 'iIEALV <br /> (Complete in Triplicate) Ei�lUpzmtl+,I};Ei2UlCf±6 <br /> n Local Health District for a permit to construct and/or install the work herein described. This application is <br /> Application is hereby made to the San Joaqui <br /> ge or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for sewa <br /> Local Health District. 71) <br /> +, 1) <br /> I U 7 \ b Lot Size PM <br /> Job Address — t <br /> �/V� L Address L , o 1 Phone <br /> Owner's Name r / <br /> Contractor <br /> OL. �� Address�� License No. 6 V Phone GL� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LlDESTR CTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP_ L1NE } <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r <br /> ' ❑ Industrial EI Open Bottom _ 0 Manteca Dia. of Wel.Excavation Dia.-of Well-Casing <br /> 1Domestic/Private ❑ Gravel Pack D Tracy Type of Casing Specifications <br /> n Public Cl Other i FA Delta Depth of Grout Seal Type of Grout <br /> i <br /> 1 1 Irrigation _._Approx. Depth ,S rfac �eal Installed by � ,S <br /> H.p. Z► State Work Done s <br /> Repair Work Done ❑ Type of Pump <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth <br /> Filler Material {Below 501 F <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION € I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other <br /> cH <br /> a Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: °Water table depth ` <br /> SEPTIC TANK ❑ Type/Mfg `Capacity a No. Compartments s r <br /> ` 1 <br /> PKG. TREATMENT PLT" ❑ I ! 1 + Method o1 Disposal <br /> i a .... <br /> I Distance to nearest: Welt Foundation "_Property Line <br /> S <br /> LEACHING LINE ❑ No. & Length of lines M Total lengthlsize <br /> { <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth - Size Number <br /> t <br /> t SUMPS Ll Distance to nearest: Wel! Foundation Property Line <br /> - <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. 1 <br /> Home owner licensed agent'i 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 p r nin such.manner as-to become subject to-workman's-compensation-laws of-California:'-Gontractor's hiring or su4i contracting signature" <br /> certifies the f II ing: " ify that in the ormance f the work for which this permit is issued,I shall employ persons subject to workman's compensa <br /> tion laws of a ornia. <br /> The appli st c uire in ti ns. C plate drawing on reverse side. <br /> Signed <br /> Title: — �?"�`�t r��* Date: r LXi <br /> F. EPA TM NT USE ONLY <br /> -r Y:S7– <br /> Application Accepted by Date LC2 Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Date f�? <br /> Additional Comments: <br /> ❑ Stk 466-6781 0 Lodi 369-3621 El Manteca 1323-7104 0 Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA <br /> FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED 6CK NY DATE PERMi7'NO. <br /> INFO //' <br /> +.EH 13-24 MEV.5/H 51 � <br /> EH 14-2a <br />