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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA � � 4 <br /> �JTelephone (209) 466-6781 <br /> V rI 1 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> sz <br /> {Complete in Triplicate} �, n '1 `�� <br /> t�e�. This applicati -s <br /> Application is hereby made to the nCounquin y Ord nalnce No.549 for sewage o ealth District for a permit <br /> No 1862 forcwellldpuor install the work mp and the Runes and(Regulations of t}� <br /> made in compliance with San Joaquinr- <br /> Local Health District. -}A p�/� �Td/� 1���! �N �R � ��v�G�S r <br /> City Lot Size I'ftA <br /> Job Address `- LO <br /> �I <br /> Address <br /> Rhone <br /> Owner's Name d-S� `' <br /> UJ - a <br /> Contractor <br /> Address License No. Phone <br /> TYPE OF WELL/PUMP: NLVV WELL ❑ WELL REPLACEMENT El DESTRUCTION El <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> SEWER LINES DISPOSAL FLD, PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK f <br /> FOUNDATION AGRICULTURE WELL - OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL` PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Specifications <br /> El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Type of Grout <br /> M Public n Other ❑ Delta Depth of Grout Seal <br /> I Irrigation =�-Approx._Qep_th_ l 1 Eastern Seal Installed by <br /> Repair Work Done ❑ Type of Pump — <br /> 4, z__.State State Work Done % <br /> Well Destruction ❑ Well Diameter Sealing Material tt kp 50'1 <br /> Depth--- Filler Material (Below '•) r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1_1—EEP-AIRJA___ ___ l ] DES �UGTION I I available 1within 200 feetstem .) if publicJs ­ <br /> �newesv <br /> Installation will sere: Residence.- Commercial— Other Number of living units: Number of bedroom's�� - Water table depth <br /> Character of soil to a depth of 3 feet: �� ��i ll�� tSEPTIC-TAMC _.0Type/MfgLJ 1 .� Capacity-� — Nopartments--.�.� � Method of.DisposakPKG. TREATMENT PLT. ❑ Distance ttWell Foundation "" -Property Line. <br /> i ! Tot`al;`lengthsize <br /> LEACHING LINE ❑ No. Length off lines j Lry.y <br /> FILTER BED <br /> ❑ Distance to neare�t: Well Foundation Property�ine <br /> i ? Number� <br /> SEEPAGE PITS 11 Depth I SF ` r;�s r <br /> � <br /> i SUMPS Ll Distance to nearest: WeiIY i FoundatigrProperty tine w <br /> f DISPOSAL PONOS ❑ <br /> 1 hereby certify that I have prepared this application and that the work will be dans in accordance with San.Joaquin county ordinances, state laws, - <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies\he-fbllowingr"I certify that iftperformance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject tc workman's c pert tion laws of California." Contractor's hiring or sub contracting signature <br /> certifies the following- "I certify that in the performance ofThe_w4w:_c-f which his permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California.' {.._��`'��_ <br /> The applicant F requir oms.r Com ate drawing on reverse_ids. <br /> Title: l �-� Date: <br /> Signed X JJ <br /> i AOR DEPARTMENT USE ONL �L ' <br /> Date a" — Area <br /> Application Acceptedby -- - ,/ <br /> Pit or Grout Inspectio <br /> Dat€+ Final Inspection by Date '% — <br /> Additional Comments: <br /> p Stk 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 CK RECEIVED BY DATE PERMIT NO. <br /> AMOUNT DUE AMOU Mil CASH <br /> INFO <br /> +.EH t3-241REV.ris+51 <br /> EH 14.28 <br />