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- a APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i ON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 A <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) application is <br /> e r t t con fort an pump and the Rules and Regulations of the San Joaquin <br /> Application is hereby made to the San Joaquin �dinance Na.ocal Health 549 for ser permit to construct and/or install the work herein described.This <br /> made in compliance with San�J,o`a51 County O 1 <br /> Local Health District., PM <br /> City Lot Size 101 1'959d-1 <br /> Job Address2 3 <br /> \N Phone <br /> Address,r <br /> Owner's Name y� "-;rj <br /> / �.Or License No. % Phone <br /> ddress w <br /> Contractor WELL REPLACEMENT ❑ DESTRUCTION ❑ t <br /> NEW WELL ❑ 1 <br /> i ,ITYPE OF WOTHER ❑ELLIPUMP: SYSTEM REPAIR ❑ <br /> PUMP INSTALLATION ❑ DISPOSAL FLD. PROP. LINE ; <br /> SEWER LINES <br /> PITS/SUMPS <br /> DISTANCE To NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL <br /> FOUNDATION �— <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSpia. of Well Casing <br /> �a <br /> INTENDED USE ❑ Manteca Dia. of Well Excavation <br /> ❑ Industrial ❑ Open Bottom Specifications <br /> f i Q Tracy Type of Casing------- �:; Type of Grout' <br /> Q Domestic/Private ❑ Gravel Pack <br /> It❑ Public ❑ Other <br /> ❑ pelta Depth of Grout Sea! <br /> �gpprox. Depth ❑ Eastern Surface Seal installed by <br /> i irrigation State Work Done J <br /> ' v' Type of Pump H.P. <br /> Repair Work Done ❑ Sealing Material (top 50'1 T <br /> r Well Destruction ❑ Well Diameter Filler Material {Below 50'! <br /> f Depth rmitted if public sewer is <br /> r „ available within 200 feet.? <br /> ! TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION ❑ DESTRUCTION ❑ (No septic system pe <br /> F F �� <br /> i' Commercial Other�— <br /> Installation will serve: Residence <br /> : of living units: oNumber of be oms Water table depth <br /> . Number <br /> Character of sail to a depth of 3 feet: Capacity No. Compartments <br /> ` Type/Mfg Q Typeg <br /> y SEPTICaTANK Method of Disposal <br /> PKG. TREATMENT PLT. ❑ tion Property Line ------.--�– <br /> �� <br /> Distance to na ri W Founda_ <br /> Total length/size i <br /> !LEACHING LINE ❑�No. & Length of lines Foundation -- Property Line <br /> l ;FILTER SED _ EJ Distance to nearest: Well u <br /> Size Number � ? <br /> SEEPAGE PITS ❑ Depth ( Foundation s Prope'ty Line ' <br /> SUMPS. _ ❑ t5ist na ce to nearest: f Wel!i <br /> _,1.01 4-:% ' and <br /> �DlspOSALPO� NDS `❑ <br /> I hereby certify that have-prepared this applic HI n and <br /> that the work will be done in accordance"`"�itthe work for Joaquin <br /> which this permit is$ssued, I s, state hall not <br /> } rules and"regulations&the San Joaquin Local I certify that in the performance of. <br /> Home owner or_licensed.agen`t's signatrirb certifies the following: " nsation laws of California:"Contractor's hiring or sub-contracting signature <br /> employ'any person in's"uch manner as tobecomesubject to workman's comps ; <br /> certifi y'a.nys"the person <br /> "1 certify that in the performance of the work for which this permit is issued,I shall employ:personuubject to workman's compens <br /> tion�ws of California." �-�– t .\. _ <br /> 1 E <br /> The applicant ust call for 1 required inspections. Complete'd`awing on reverse*11 side. Date: <br /> Title. x <br /> Signed <br /> FOR DEPARTMENT USE ONLY } <br /> F <br /> Date Area <br /> Application Accepted by Dat <br /> Dat I Final Inspection b f <br /> ror Grout Inspection by <br /> I' <br /> S ' 1 <br /> Additional Comments:❑ ❑ Manteca 823-7104 ❑Tracy 83543M Stk., CR 95201 <br /> Applicant- Return all copies to: E <br /> k -Stk 466-6781 [3 Lodi 369-3621 <br /> � nvironmental Health Permit/Serv�ces 1601 E. Hazelton Ave., P.O. Box 2009, <br /> i CKDATE PERMIT''NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED F <br /> CASH RECEIVED BY <br /> INFO 4 <br /> +EH 11&24 IREV.i>e 51 � - - ,•--. �• --- x"'--.---- � YYY"' <br /> EH 1428 <br />