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u: APPLICATION FOR PERMIT <br /> Nr{ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. }{AZEL i ON AVE., STOCKTON# CA <br /> Telephone 1209! 466-6181 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) This application is <br /> truct anWor <br /> ll the work <br /> Application is hereby made to the <br /> San Joaquin Local Health District for a <br /> permitto <br /> far 11/pump and the Rules and rRegu al ti M of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or <br /> Local Health District. PM <br /> g�j F 1 xt I . D a• city UcTa Lot size <br /> AVS. se 9 <br /> Job Address oc S 5TOCKTC(4 915201 Phone 94�Z+ 14� <br /> aTRIr- Ca. �c�• S 994-m�G1� Address <br /> Owner's Name I Phone�2"{ <br /> Sa✓►'t C License No.��-- <br /> SAM� Address DESTRUCTION ❑ <br /> Contractor Nay WELL�I WELL REPLACEMENT ❑ OTHER ❑ <br /> SYSTEM REPAIR ❑ <br /> TYPE OF WELLIPUMP: �. PROP. LINE 2 5 <br /> k PUMP INSTALLATION C3DISPOSALFLD.�- 1 <br /> SEWER LINES PITS/SUMPS <br /> V DISTANCE TO NEAREST: SEPTIC TANK --=— AGRICULTURE WELL OTHER WELL1— <br /> FOUNDATION —� w. <br /> i CONSTRUCTION SPECIFICATIONS <br /> TYPE OF WELL PROBLEM yp+ Dia. of Well Casing <br />' INTENDED USE ❑ Manteca Dia. of Well Excavation rP�G Specifications <br /> X Open Bottom Type of Casing <br /> ❑ Industrial ❑ Tracy g7► Type of Grout <br /> I O Domestic!Private ❑ Gravel Pack <br /> ❑ Delta Depth of Grout Seal <br /> ❑ Public ❑ Other Surface Seal Installed by <br /> ticnAA�E- XZ�pprox. Depth El Ea .� State Work Done <br /> � tSvt3E H.P. <br /> Repair Work Done ❑ Type of Pump <br /> Sealing Material {top 50') + <br /> Well Destruction ❑ Well Diameter l— Filler Material (Below 50'} <br /> Depth tic system permitted if public sewer is <br /> x available within 200 feet.} <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIAD11TlON ❑ DESTRUCTION ❑ o�P <br /> Commercial— Other <br /> Installation will serve: Residence— <br /> i Number of Vining units: <br /> Number of bedrooms I Water table depth <br /> f Character of soil to a depth of 3 feet: Capacity-- 1 No. Compartments a <br /> I <br /> SEPTIC TANK [J Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Foundation_��— Property Line <br /> Distance to nearest: Well <br /> , <br /> k' <br /> Total length tsize <br /> LEACHING LINE ❑ No. & Length of lines ' property Line—�— <br /> FILTER BED C] Distance to nearest: Well <br /> Foundation <br /> Size Number <br /> SEEPAGE PITS. El Depth Property Line <br /> SUMPS ❑ Distance to nearest: Well <br /> Foundation <br /> DISPOSAL PONDS ❑ ill be done in accordance with San Joaquin c <br /> I hereby certify that I have prepared this application and that the work will <br /> ordinances, state laws, an <br /> rules and regulations of the San Joaquin Local Health District. performance of the work for which this permit is issued, <br /> I shall not <br /> k Home owner or licensed agent's signature certifies the following: "140 rtify that in the <br /> in the rformance of the work for which this permit is issued,I shall employ persons subject to workman's compense- <br /> hat$to become subject to workman's compensation pelaws of California." Contractors hiring or sub-contracting signature <br /> employ any person in such mann <br /> er i certifies the following:"I certify t <br /> tion laws of California." " <br /> The applicant ust c I fo all require inspections. Complete drawing on reverse AGR-ES�� p� Date: `8 0 <br /> Title: r <br /> Signed FFFY���+++���� <br /> F R EPARTMENT USE ONLY r� <br /> Dat 2�� rea—�$ <br /> Application Accepted at <br /> Date Final I on by , <br /> Pit or Grout Inspect y <br /> Additional Comments: ❑ Manteca 823-7 ❑ Tracy <br /> ❑ 5tk 466-6781.. Lad( 369-3621 Stk., CA 95201 <br /> Applicant- Return all copies to: Environmental Health PermitJServi s 1601 E. Hazelton Ave., P.O. Box 2009. <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> CK RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> + EH 13-24(REV.It 5 5) e., - E)d <br /> EH 14-28 <br />