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- APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL—I ON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> FIRES 1YEAR r-ROM DATE ISSUED <br /> PERMIT EX � <br /> (Complete in Triplicate) / rr�� lication is. <br /> �64n%o <br /> ,{ ?Ih <br /> `� or No. 1862 for welllpump and the Rules and Regulations of the San Joaquinhereb made o the San Joaquin Local Health Qistfor sewagermit to construct andlor i st Il a wor er�ein a ribed. This appAis Y <br /> made in compliance witrh San JDagwn County Ordinance No.549 <br /> Local Health-District Com`j 7J <br /> $'.�!�C.J� ��7h[�®f Lot Size VW PM <br /> Cit — <br /> Job Address _ I L�a� J hone <br /> G ��n3 W 17 <br /> S r1 r Address <br /> Owner's Name Phone_ <br /> License No. <br /> Address DESTRUCTION ❑ <br /> Contractor WELL flEPLACEMENT ❑ <br /> NEW WELL ❑ OTHER ❑ <br /> TYPE OF WELLIPUMP: <br /> PUMP INSTALLATION 11SYSTEM REPAIR CIDISPOSAL FLD. PROP. LINE <br /> SEWER LINES —149—x— PITSISUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL— <br /> FOUNDATION r— i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> ❑ Open Bottom Ll Manteca Dia. of Well Excavation Specifications (J� <br /> ❑ idustrial [I Tracy Type of Casing <br /> ' pomestic/Private ❑ Gravel Pack Type of Grout <br /> Cl Other CI Delta Depth of Grout Seal <br /> f'1 Public Surface Seal Installed by <br /> ' I I Irrigation �.-Apprax. Depth 4 I Eastern State Work Done 1- <br /> T e of Pump �--- H.P. <br /> Repair Work Done LJ Type Sealing Material (top 501 <br /> Well Destruction ❑ Well Diameter <br /> Filler Material (Below 501 <br /> Depth (� <br /> available within 200 feet.l <br /> TYPE OF 51=PTIC WORK: NEW INSTALLATION I 1 <br /> REPAIR/ADDITION ( l QESTRUCTION (No septic system permitted if public sewer i <br /> Installation will serve: Residence Commercial— Other_�--- <br /> Number of living units: Number of bedrooms Water table depth f, <br /> Character of soil to a depth of 3 feet: Capacity- No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of DisposalLA <br /> PKG. TREATMENT PLT. ❑ Foundation r- Property Line��-- <br /> Distance to nearest: Well <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Property Line <br /> FILTER BED ❑ Distance to nearest: Well <br /> Foundation <br /> Number <br /> i I Dept �. <br /> SEEPAGE PITS h Size Foundation�--- Property Line�—�— <br /> SUMPS D Distance to nearest: Well <br /> DISPOSAL PONDS ❑ <br /> 1 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 District I certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: ' arsons subject u workman's signal sa- <br /> employ any person in such manner as <br /> tobecome subject to workman's he work for which this compensation <br /> permit4is rssued1f shall employ Ptor s hiring c sub contracting signature <br /> certifies the following-."I certify that pe <br /> tion laws of California." J/ <br /> The applicant mu �frll require�inspections. Co plate drawing on re�Q��d� pate:�q Title: <br /> Signed X V <br /> R DEPARTMENT USE ONLY pQ <br /> Date <br /> r rp O Area <br /> Application Accepted by Date <br /> Date �- Final Inspection by <br /> Pit or Grout Inspection by �' W 11 5� d 0 S� <br /> Additional Comments: ❑ Tracy 835-6385 <br /> ❑ Stk 466-6781 Lodi 3 3621 ❑ Manteca 823-7104 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.; P.O. Box 2009, Stk., GA 95201 f <br /> RECEIVED 9Y DATE PERMIYNO, <br /> FEE AMOUNT DUEMnN <br /> INFO EH 13-24 IREV. /H 5Y . <br /> EH 14-26 - - - - -- - <br />