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' APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA FILE <br /> C <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> ll the work <br /> cation is <br /> Application is hereby made a oJoaqu nn Joaquin County Ordinancie No.549 for sewage ealth District for a permit <br /> r'No. 1862 forct and/or weupump and the Rules and hereinR gulations of he San Joaquin <br /> made in compliance w <br /> Local Health District. <br /> City Lot Size r PM <br /> Job Address -- <br /> 711 Phone <br /> Owner's Name S, <br /> A) &rp?o Address <br /> �/) �I D e/ License No. Phone *�V <br /> Contractor /�+ v Address <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR CI OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTE_NDEb USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial f <br /> D Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Type of Casing Specifications <br /> ❑ Domestic/Private ❑ TGravel Pack ❑ Tracy YP g Type of Grout ; <br /> f"1 Public P Other 171 Delta Depth of Grout Seal YP <br /> 1 1 Irrigation �_Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Lone D Type of Pump H,P. State Work Done_ <br /> Well Destruction L1 Well Diameter Sealing Material (tap 50'1 <br /> i Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAlR1ADDITION I ! DESTRUCTION l 1 availableseptic <br /> within 200 feet.) if public sewer is <br /> Installation ill serve: Residence L.--Commercial4 "Other <br /> Number of9iving units: Number of b drooms ; r k <br /> Character of soil to a depth of.3 feet: O�,�► :. �? �, Water table,lep <br /> SEPO�TypelMfg <br /> Capacity_.� — No . Cgrfipd,tments <br /> TIC TAN �t <br /> Method LP' Rosal I <br /> PKG. TREATMENT PLT. ❑ ? - t � Ii <br /> Distance t nearest:: Well ( Foundatibn_L�«—� os <br /> Property Line <br /> l LEACHING L NE L1- N9- & Lenofi Orr, es +�7 '"�' � r Y j Total length/size � <br /> FILTER BED ❑ Distance to nearest: Well f Foundation - Property Line . <br /> SEEPAGE PITS i"l'Depth S1ze k Number <br /> I ❑. Distance to nearest: Well s Foundatison-�l--t. Line <br /> SUMPS „r <br /> DISPOSAL PONDS ❑. F <br /> hereby certify that I have prepared this application and that he work will be done in accordance with San Joaquin county ordinances, state lalrr :and <br /> rules and regulations of the San Joaquin Local Health District. "K <br /> Home ownerjor licensed agent's signature certifies the following: "1 certify that in the pijfformance of the work for which this permit is issued, l shall not <br /> employ any Pierson in such manner as to become subject to workman's compensation-taws of California."Contractor's hiring or sub-conf/acting 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 compensa- <br /> tion laws of ialifornia." <br /> t <br /> The appiican must call for all equ' d inspections. Complete drawing on reverse side. <br /> Title: Date: ?"pv <br /> FOR DEPARTMENT USE ONLY <br /> Application ccepted by DateArea I <br /> ` <br /> I Date. y/-O�Final,_Inspection_by. " "Qdte� <br /> E �t or Grout,. s".I;iQn by„_ <br /> Additional Comments: <br /> a ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 955201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY 1]ATE PERMIT NO. <br /> + EH 13-24(REV.1/n51 INFO A` 4� <br /> EH 14-26 <br />