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..........F •. _. . —�-� `� 315v <br /> f <br /> �• APPLICATION FOR PERMIT <br /> r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON,`AVI STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> aquin LocHealth District for a <br /> is <br /> cation <br /> Applicatios a San Joe S n County O d napermit Construct install <br /> n Jo nce No. 549 for sewage or No 1862 forwell/pump and the Rul s and R gulations of the Sanl Joaquin _ <br /> made in compliance with <br /> Local Health District. <br /> 7 H -� City .G�l �t}Size PM <br /> Job Address I <br /> Owner's Name Address Phone <br /> License No.L(Q -Phone S"!5_6 <br /> Contractor ; <br /> WELL REPLA DESTRUCTIO <br /> TYPE OF;WELLIPUMP_ NEW WELL I SYSTEM REPAIR OTHER ❑ <br /> PUMP INSTALLATION I� y Z f /4 FAIT <br /> DISPOSAL FLD.__� PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK sZ..f.�-- SEWER LINES -.� <br /> FOUNDATION r? AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION ;. <br /> ❑ In stria) Cl Offen Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> —/ r Sp Ifications <br /> Domestic!Private lf�Gravel Pack ❑ Tracy,,. Type of Casing f r <br /> FI Public [1 Other Ll Delta ^� <br /> Depth of Grout Seat yp of Grou <br /> I 1 Irrigation AzApprox. Depth i I E tern �' %Surface Seal Installed by <br /> H P to Work one <br /> Repair Work Done ❑ Type of Pump �,j <br /> Well Destruction I� Well Diameter Sealing Material Itop 50') ` <br /> Depth Filler Material 113490w 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION I I `DESTRUCTION I I (No septic systhin 200 feet.) <br /> ed if public sewer is <br /> Installafron will serve: Residence— Commercial— Other <br /> Nurftber of'Iiving units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK4 �. ❑ Type/Mfg (Capacity No. Compartments <br /> �` Method of Disposal <br /> PKG. TREATMENT PLT:,❑ <br /> Distance to nearest: Well Foundation Property Line <br /> . lr N <br /> _ f <br /> 4LEACHING LINE ❑ No <br /> & Length of lines F .4 Total length/size' <br /> w. r ,� Pro rt Lines ° <br /> FILTER BED ❑ Distance,to nearest: Well Foundation Pe Y ` <br /> '-` �+. .Size Number <br /> SEEPAGE PITS I'-•1 Depth <br /> i, <br /> MOS �� i Li"'IDistance to nearest: / Well Foundation Property Line <br /> DISP05AL PONDS <br /> I hereby certify that I-have prepared thisrapplication 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 District. <br /> Home owner or n; agent's siggature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any !son in esu manne�,as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies th following: "I rtify thafin a parlor c of the work for which th' rmit is issued, I shall employ persons subject to workman's compensa <br /> tion law of Califor Ia." ' <br /> The ap ice tali or aI do m ate drawing o rev Itl Ag r / — J a <br /> Signed <br /> Title: Date: d <br /> i FPR DEPARTMENT USE ONLY <br /> Date Area �� <br /> Application Accelited by <br /> I s, Ido® <br /> Date oTg� Final Inspection by Date <br /> Pit or Grout Inspection by yfm s�a^' <br /> ' j2 <br /> Additional Comments: � ,:�! � <br /> ❑ Stk 466-6781 El Lodi 369-3621 11anteca 823 104 ❑ Tracy 836-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2609, Stk., CA 95201 <br /> FEE CK RECEIVED BY DATE PERMIT'NO. �J <br /> INFO MOUNT DUE AMOUNT REMITTED CASH <br /> a <br /> +.EH13-24IREV.tiiKs1 4r I el <br /> EH t4-Z8 <br />