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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) - 1 �. 1 <br /> r •> <br /> M, <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> work <br /> ion is <br /> Application is herebymadeto the San Joanui ordinance No.District Health 549 o sewage or permit <br /> 1662 for well/pump and he Rules and 1Regutatio�of th San Joaquin,, <br /> made in compliance with San Joaquin County <br /> Local Health D•rstrict. ` <br /> fit- I <br /> Clty'�"=-'"Y#-= Lot <br /> Si. Pm <br /> Job Address r`pp ?. 3G •OW <br /> Y'LS 1 dr Phone C1 <br /> Owner's Name_ �' p Address pp �+ <br /> t7.'D 1 ; Phone <br /> Contractor's Name r License No. i <br /> TYPE Of WEI.LlPUMP: NEW WELL Q WELL REPLACEMENT ❑ DESTRUCTION F1 <br /> SYSTEM REPAIR ❑ OTHER -:1 <br /> PUMP INSTALLATION ❑ DISPOSAL FLO. PROP. LINE <br /> DISTANCE TO NEAREST. SEPTIC TANK SEWER LINES <br /> FOUNDATION <br /> AGRICULTURE WELL OTHER WELL -PITS/SUMPS <br /> � <br /> INTENDED USE T_ OF WELL PROBLEM AREA CONSTRUCTION SPECkFICATIONS <br /> TYPE Dia of Well Casing. <br /> ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications I <br /> f <br /> ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing4 Type of Grout <br /> Depth of Grout Seal >i <br /> I] Other [I Dena. ❑ Public -S't* <br /> Seal Installed by <br /> C] irrigation _--Approx. Depth 12Eaatem 't State Work Done <br /> Repair Work Done ❑ Type of Pump H.P. lop <br /> �. <br /> Well Destruction ❑ Well Diameter Seating Materia.- 1.501 j <br /> Depth Filler Material(Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION C] REPAIR/ADDITION DESTRUCTION❑ available se ttiwi st em 206 feet.) <br /> if public sewer is <br /> i <br /> ` Installation will serve: Residence c..-, Commercial_ Other u ` <br /> r Number of living units: �— Number of bedrooms ': Water table depth �� r <br /> i -� a01M !!! <br /> Character of soil to a depth of 3 feet: _No Compartments <br /> Capacity _,-�-_— <br /> SEPTIC TANK E3 Ty __ �_ j. Method of.Disposal <br /> PKG TREATMENT PLT.❑ P bperty Line <br /> Distance to nearest: Well Foundation I p �• r I <br /> I l <br /> i .fj d f <br /> Total lengthli3ize <br /> LEACHING LINE 20—No. &Length of lines 1� _ Property Line'f9 <br /> Distance to nearest Well �Q Foundation r <br /> FILTER BED ❑ <br /> ! if v 9 c Number 1 ' <br /> SEEPAGE PITS 9--Depth =� Sire J ' Foundation " Property Line i_ <br /> SUMPS ❑ Distance•to-naarest: Weil — f r <br /> DISPOSAL PONDS ❑. <br /> ! --- a►, <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaq n county ordinances,state laws,and <br /> rules and regulations of the San Joaquin Local Health District. ' <br /> Honig owner or licensed seen(s,signafure certifies the,following:.s I certify that in the performance of the work for whach this pemvt is issued,1 shall not <br /> ng nature <br /> employ any person in such manner as to become subiect'to V*Vkman's oompensationmlaws�edrf shall employ persons`subject t workman's componsa- <br /> certifies the following:"I certify that in the performance of the wo for which this pew <br /> tion lava of California." � ti <br /> The applicant must call for ,-required Inspections. Complete drawing on reverse side. r <br /> 4 Tile:1­0" �r[,yc_ i i Date: <br /> Signed <br /> 1 <br /> FOR DEPARTMENT USE ONLY. <br /> I Date r�_ , _ 0 ! <br /> Application Accepted by ` A ��f i <br /> �i Grout Inspection by <br /> ._ Date �f Final InBpectio by Ile <br /> Additional Comments: -..+-=- ^^ "`• <br /> [IStkl`466-6781^ter^-❑ Lodi­369-3621--r--❑,Menteca-823°7404 . C3- -Tracy-BM-M <br /> Applicant•Return all copies to: Environmental Health Permit/Services 160`1 E. Hazelton Ave.*,P.O. Bar 2009, Stk.iCA 95201 <br /> / <br /> RECEIVED BY DATE: PERMIT No. <br /> FEE AMOUNT DU[ 5"A�AOUNT REMITTED CABM <br /> y INFO //�� // I. pl !jam <br /> i EH 13-24(REV.10/83) I o xel tr <br /> EH 14-28 <br />