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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT PAY&1jEf47. <br /> 1601 E. HAZELTON AVE., STOCKTON, CA FIECEIVS0 <br /> Telephone (209) 466-6781 APR 19 1993 <br /> PERMIT,EXPIRES.1 .YEAR FROM DATE ISSUED SANJ©AQl1INPUBLI <br /> (Complete in Triplicate) ENVI c SERVSig <br /> COUNTY <br /> Application is he+eby made to the San Joaquin Local Health District for a permit to construct and/or install the wor r � cation is <br /> made in compliance with San Joaquin County Ordinance No. 5491or sewage or No. 1862 for well/pump and the Rules and Regulations Joaquin <br /> Local Health District. <br /> City tot Size PM 1111 <br /> Job Address i <br /> PGRI,.CY [�-L-�. s - `S A Phone <br /> Owner's Name _ Address <br /> ContractorIZ co/nLo � �A�-Address 020ag License No5q 9�0 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL. = -- --P{TS/SUMPS <br /> INTENDED USE (TYPE OF WELL PROBLEM AREA CONSTRUCTION.SPECIFICATIONS <br /> © Industria) 0 Open Bottom LJ Manteca Dia. of Well Excavation <br /> T <br /> I Dia. of Well Casing <br /> Type XDomesticlPrivate ❑ Gravel Pack ❑ Tracy - - YP of Casing Specifications <br /> I <br /> Cl Other y n Delta- t Depth of Grout Seal Type of Grout <br /> F"1 Public 1' i:.t'*.` a ; <br /> ! Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by 60� <br /> � p H.P. 3 State Work Done <br /> Repair Work Done Type of Pump H.P. <br /> I Well Destruction ElWell Diameter st Sealing Material /top 50') ` r <br /> Filler Materiai /Below 501 r r <br /> Depth - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADDITION I 1 DESTRUCTION l 1 (No,septic system permitted if public sewer is <br /> available Adepth <br /> ) <br /> Installation will serve: Residence_ Commercial Other .,1 <br /> Number of living units: ' Number of bedrooms <br /> Character of soil to a depth of 3 feet: ' Wa <br /> SEPTIC TANK ❑- Type/Mfg Capacity NoPKG. TREATMENT PLT. ❑ Melpistanceto nearest: Well Foundation Property <br /> k <br /> tTotal length/size <br /> LEACHING LINE ❑; No. & Length of lines <br /> FILTER BED 1-1k Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS t 11 Depth Size r `" '' Number <br /> SUMPS LlDistance to nearest: Well Foundation Property Line <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 /> r rules and regulations of the San Joaquin Local Health District. <br /> 1.Home owner or licensed ageht's 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 person in such manner as to become subject to workman's compensation laws of California," Contractor's hiring or sub-contracting.signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ,persons subject to workman's cornpensa- <br /> tion laws of California." "- <br /> ` v , ,:N V; <br /> The applicant mupoir#for al require �pecti ns. Complete drawing on reverse side. Q <br /> Signed X T -Title: <br /> R p RTME SE ONLY <br /> Application Accepted by <br /> Date Area <br /> Pit or Grout inspection by <br /> Date + Final inspection by Date <br /> I Additional Comments: <br /> k ❑ 5tk 466-6781 El Lodi 369-3621 ❑ Mantata 823-7104 ❑ Tracy 835-6385 <br /> Permit/Services 1601 E. Hazelton Ave.; P.O. Box 2009, Stk., CA 95201 <br /> Applicant - Return all copies to: Environmental Health <br /> f FEE AMOUNTDUE AMOUNT REMITTED K RECEIVED$Y DATE PERMIT NO. <br /> INFO H <br /> r EH 1324(REV.i/H 5 <br /> EH 14-26 <br />