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I{ y APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE:,TON AVE.. STOCKTON, CA <br /> r TelephoneIM)466-6781 <br /> PERMIT EXPIRES T YEAR FROM DATE ISSUED <br /> lComplete in Triplicate? <br /> Application is he+eby made M the San JoataWl►LoeN'Neatdt'Oletf((x ioi.tarimit•torid �t=tr► tall the+�iorlt#terein descrt�ed.`Yftis application is <br /> made in compliance with San Joaquin County Ordinance Na$l9.toraevvage or No 11�,�01 we$fNLmp and the Rutas and Regulations of the San Joaquin <br /> `Local Health District. <br /> Job Address -Be rlIQIYIiI2If' Fnh✓� CifyS�bCx�DrTt lot Sim /SOX /$$ PM <br /> C&- /610 <br /> Owner's Name _ Ad( p� an'LGCLCc. <br /> � <br /> .San �ia'tra. 49 Phi /- 240 <br /> 1765 $oa4s%- �2occd <br /> ContractorPr- Address D ✓' License No.al0555(o Phone / -77 3 <br /> TYPE OF WELL/PUMP: NEW WELL IN µ W L REPLACEMENT O DESTRUCTION O <br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> S" &qare (eneloud]POUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE, TYPE-,OF WELL,?.-,. PROBLEM AREA ,I:CONSTRUCTION SPECIFICATIONS <br /> 01ndustitiiai O Open Bottom* ...O Manteca` " L Dia.of Well Excavation I2 r Dia:of Wen Casing �'rz <br /> O Domestic/Private O Gravel Pack O Tracy Type of Casing PVe— 5CA- 40 Specifications <br /> O Public n Other n.pelta Depth of Grout Seal Type of Groutl4gaf <br /> I 1 Irrigation —Approx. Depth, I I Eastern Surface Seal Installed by r, <br /> Repair Work Done O Type of Pump H.P. State Work Done <br /> +( Well Destruction O Well Diameter a Sealing Material(top 50') <br /> "i mOY/i'F Dr�n mpth'-1 3 O 4-CP " Filler Material(Below 50') <br /> T PE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l 1 DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Insta�IaseResidence_ Commercial_ Other <br /> NumNumber of bedrooms <br /> -Character of soil to a depth o Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.O Method of Disposal <br /> Distance to nearest: Well <br /> our, <br /> Property Line <br /> LEACHING LINE ❑ No. b Length of lines of th/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Lin <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <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. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, f 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, 1 shall employ persons subject to workman's compensa- <br /> tion laws of Califa." <br /> The applicant 1ucall for all regyire04ns ions. Complete drawing on reverse side. <br /> Signed X -7Z i/ r <br /> Title Date: <br /> ., FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 4 Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> O Stk 166-6781 O Lodi 369-3621 O Manteca 823-7104 O 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 AMOUNT DUERNT REMITTED <br /> INFOCASH RECEIVED BY DATE "PERMInT,NCO. <br /> . EH 13-24(REV.1,, - ` _ <br />