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APPLICATION FOR PERMIT It t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 9 <br /> n PERMIT EXPIRES 7'YEAR FROM DATE ISSUED <br /> l ✓"�� �� (Complete in Triplicate) <br /> mape Application is hereby once made t Joaquin San <br /> n County ordThis application is <br /> Joaquin inance No.549al Health rfor sewage or ict for a permit <br /> 1852 for cwetupump and the Rules and'Regulations of the San Joaquin <br /> in <br /> ith <br /> Local Health District. - 1 I' <br /> C!�( c. C'� City _r-r/i Lot Size PM 1 <br /> Job Address —�-�'t h <br /> �� Phone <br /> Owner's Name la-d 4grey,---�`' Address St�O w Ifdwr <br /> Qd-U 1YGcX;-C tt License Na. Phone y2 <br /> Contraator Address D N ✓ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O <br /> " <br /> "PUMP-IRSTAL'LATION'O""!"��" SYSTEM REPAIR — OTHER'O <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION <br /> AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _Dia..of Well Casing <br /> Industrial Open Bottom ❑ Manteca Dia. of Well Excavation ... Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing-_-- <br /> Fl Delta Depth of Grout Seal Type of Grout <br /> (1 Public ❑Other <br /> I I Irrigation 300Approx, Dept I I Eastern Surface Seal Installed by IA'!O✓{ <br /> Repair Work Done I[ Type of Pump L&/ t r <br /> H P �Q State WeX Done o& <br /> Well Destruction El Well Diameter iP Sealing Material (top 50'1 — <br /> Depth ��� Filler Material (Below WI y <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION I I •aNailablettwithin 20stern last.) <br /> ed if public sewer is <br /> Installation will serve: Residence_ Commercial_ Other \ <br /> VI Number of living units:_ Number of bedrooms o r <br /> Wafer table depth <br /> i Character of soil to a depth of 3 feet:tl , No. Cbmpartments SEPTIC TANK ❑ Type/Mfg Capacity <br /> Method of Disposal <br /> i PKG. TREATMENT PLT.❑ <br /> Distance to nearer: Well Foundation Property line <br /> i Total length/size Y <br /> LEACHING LINE ❑ No. 6 Length of line "n Property Line <br /> 1 FILTER BED Ot Distance to nearest: Well Foundation P rfY <br /> EI 1 Depth Size Number <br /> k SEEPAGE PITS Property Line <br /> SUMPS O Distance to nearest: WeN Foundation <br /> DISPOSAL PONOS Cl <br /> 11 1 <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 /> rules and regulation 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, I shall not <br /> t 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:"1 certify that in the performance of the work for which this permit is issued,1 shall employ person subject to workman's compensa- <br /> tion laws of California." <br /> I The applicant must call for all required,insypections. Complete drawing an reverse side. <br /> /7 c, �/A Tide: 41 - --',••mss Date: O <br /> I signed x_t.�-. <br /> FOR DEPARTMENT USE ONLY <br /> fDate �� �-1 Area <br /> V Application Accepted by ,/gym <br /> Date ' <br /> `-A " <br /> f Final Inspection by <br /> i <br /> Pit or Grout Inspectio Date <br /> Additional Comments: <br /> ❑ Stk 455-5781 ❑ Lodi 3nviron ❑ Manteca Smicas ❑Tracy 835-6385 <br /> ` Applicant- Return all wpbs to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bos 2009.Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED ASH . RECEIVED BY DATEPERMIT NO. <br /> NFO <br /> f.Z i 85 <br /> ♦.EH M24 IREV.v M al 1 <br /> EH ILIA <br /> 1 - <br />