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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE l ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> th District for a t and/or <br /> all the work <br /> I Application is herebymade <br /> a to the San County LocalHealnce No. 549 for sewage or Permitto <br /> 1862 forcwell//pump and the Runes and hereindescribed. <br /> of the San Joaquin <br /> made in compliance �� / r-p�� oC-a <br /> Local Heath District. G <br /> Lot Size / "// Acyan-- PM <br /> L3 City <br /> Job Address .� <br /> Phone xl_ <br /> �,� <br /> ` X Owner's Name <br /> Address <br /> ' 3d wt License No. Phone <br /> r y Corrtractor h Address <br /> DESTRUCTION <br /> WELL REPLACEMENT LJDESTRULl <br /> OF WELL/PUMP: ji NEW WELL ❑ OTHER ❑ <br /> PUMP INSTALLATION F1SYST.EM REPAIR Q <br /> DISTANCE TO NEAREST: SE TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> E <br /> f FOUNDATION AGRICULTURE-WELL OTHER WELL PIT515UMPS <br /> INTENDED USE TIYPE OF WELL PROBLEM AREA' CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ElManteca Dia. of Well Excavation Specifications <br /> ❑ Domestic/Private 0 Gravel.PackA �'"�l-Tracy Type of Casing - <br /> (1 Other .' <br /> 171 Delta Depth of Grout Seal Type of Grout <br /> FI l Public �- �� - <br /> t I Irrigation _.:Approx. Depth 1 I Eastern Surface Seal Installed by <br /> ''4 H P State Work Done <br /> ' Repair Work Done ❑ Type of Pump <br /> Well Destruction (11 Weil Diameter Sealing Material )top 50") <br /> i Depth Filler Material IB w 50't <br /> TYPE OF'SEPTIC WORK: NEW INSTALLA N I 1 REPAIRlADDITlO DESTRUCTION l I atvailableSeptic <br /> wi within 200 feet.)red if Public Sewer is <br /> Installation will serve: Residence Commercial Other f <br /> Number of living units: Number of bedroom a <br /> Water table depth <br /> Character of Soil to a depth) it <br /> of 3 feet: No. Compartments <br /> SEPTIC TANK ❑ it Type/Mfg. Capacity <br /> � Method of Disposal <br /> PKG. TREATMENT PLT- ❑ II ' <br /> 1' Distance to nearest: Well : Foundation:x Property Line <br /> Ttal length/size <br /> XLEACHING LINE 4 No. & Length of lines p <br /> �, <br /> FILTER BED LD 11 �1Distance to nearest: Well Foundation `1,. Property tine-26-L— <br /> `p Number <br /> SEEPAGE PITS I•ItI Depth Size <br /> SUMPS Dista <br /> L]i rice to nearest: Well Foundation' Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and"that the work.witl be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the'San Joaquin Local Health Di%trict. <br /> Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the worts 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, l shall employ persons subject to workman's compensa- <br /> tion laws of California." 4 <br /> The applif nt ust call for II r uired inspections. Complete d�awing o revrerse side. /j; <br /> U lw G_. t --- cr�fi<-z— er Title: l -��p Date: /i��lX�7— <br /> Signed ..�"` <br /> � <br /> OR DEPARTMENT USE ONLY <br /> � «�f Date �i Area <br /> Application Asserted by JI � <br /> Pit or Grout-inspection by <br /> Date Final Inspection by J�6 Dat c` <br /> I U <br /> Additional Comments: <br /> ElStk 466-6781 ❑•,Lodi 369-3621 ❑ Manteca 823-7104 11 Tracy 835 6385 <br /> : Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, <br /> Applicant- Return all copies toSik., CA 95201 <br /> I FEE C RECEIVED BY DATE PERMIT'NO. <br /> INFO •AMOUNT pUE AMOUNT REMiTTE0 <br /> • "d r' �� b7 <br /> + EH t3-24 iREV.tin 51 - <br /> EH 14.26 <br /> ry <br />