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� - APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6181 <br /> PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED <br /> } f } < .:•� (Complete in Triplicate)ct <br /> /or install the work <br /> appl <br /> cation is <br /> Application is hereby made to the San <br /> Joaquin OrdinanceLocal <br /> No.District <br /> sewage permit <br /> to 1862 for well/construdpump and he Rules and herein <br /> described. <br /> ati of he San r Joaquin <br /> E <br /> made in compliance with San Joaquin County , <br /> Local Health District.:;,, i, .r s <br /> t2 , dA <br /> City. Lot Size PM <br /> Job Address / <br /> c, - 114 r / lQl <br /> - `'+ ,'' .��._ .1 Phone ` / i <br /> Address j <br /> Owner's Name ti x y. v Y t ® <br /> Contractor <br /> dress icense Na. Phone <br /> WELL REPLACEMENT ❑ DESTRUCT <br /> TYPE OF WE L IPU P: NEW WELL ❑ SYSTEM REPAIR ❑ w OTHER ❑ <br /> PUMP INSTALLATION ❑ <br /> SEWER LINES DISPO FLD: PROP. LINE <br /> DISTANCE TO NEAREST. SEPTIC TANK <br /> FOUNDATION � AGRICULTURE WELL ER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL !PROBLEM AREA CONST ON SPECIFICATIONS pia. of Well Casing <br /> 11 Industrial ❑ Open Bottom F❑ Manteca D- . of Well Excavation Specifications <br /> [j Domestic/Private El Gravel Pack ❑ Tracy Type of Casing <br /> I❑ Dett Depth of Grout Seat L Type of Grout <br /> ❑ Public ❑ Other r. ,� .—* � <br /> rox. Depth ' stern Surface'ySea1-Installed--UY <br /> El Irrigation --App <br /> 4F H P State Work Done <br /> Repair Work Done ❑ Type of Pum i S <br /> Well Destruction ❑ We - meter Sealing Material (top 501 <br /> Depth 3 Filler Material (Below 50') <br /> TYPE OF SEP WORK: NEW INSTALLATION•,❑ REPAIR/AQDITtON ❑; DESTRUCTION {Nailableiwithin e200 feet permitted if public sewer is <br /> installation will serve: Residence-- Commercial Other } <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments a <br /> SEPTIC TANK ❑ Type/,Mfg Capacity <br /> S g Method of Disposal <br /> PKG, TREATMENT PLT. ❑ ; Property Line f <br /> Distance to nearest: Well Foundation <br /> Totallength/siie <br /> LEACHING LINE ❑ No. & Length of linesproperty Line �' k <br /> FILTER BED ❑ Distance to nearest: .Well Foundation <br /> f <br /> SEEPAGE PITS ElDepth I Size Number <br /> I <br /> Property Line <br /> SUMPS ❑ Distance to nearest: Well Foundation P Y <br /> ` DISPOSAL PONDS ❑ - <br /> I hereby certify that I have prepared this application and that the work wiN be-done-in in act rdance with San Joaquin county ordinances, state laws,and <br /> rules and regulations of the San Joaquin Local Health District. <br /> rtify that in-the'aws of once of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I celmpensation laws of California."Contractor's hiring or sub contracting signature <br /> employ any person in such manner as to become subject to workman's co <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 California." <br /> ctio ,y <br /> The applicant m t c or r qu'ed in ns. C m to drawing o rse side. <br /> Signed Title:��. <br /> Data: (� <br /> ` OR DEP RTMENT USE ONLY <br /> 44 Date G Area�! <br /> Application Accepted by <br /> Date Final Inspection by Date <br /> Pit or Grout Inspection by s <br /> Additional Comments: <br /> ❑ Stk 466-6781 El Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> n <br /> FEE CK# RECEIVED BY DATE PERMIT'NO. <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> + EH 13-24(rIEV.1/85) <br /> EH 14-26 <br />