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r <br /> APPLICATION FOR PERMIT <br /> W, <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE.,-STOCKTON, CA <br /> Telephone (209) 466-6781. <br /> PERMIT EXPIRES'l YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> is <br /> Application is hereby made to the No.D549 for sewage or'No. 1862 for t to constructwellldpump install <br /> nd the an <br /> and Regulations iliaof the Span Joaqu ication n <br /> San <br /> in compliance-with San Joaquin County ordinance <br /> Local Health District-,;- r;rx. ,, 11 1 ' <br /> ? <br /> City S Lot Size PM <br /> •f�f�W'Q <br /> Job Address � T <br /> S <br /> SAWe Phone <br /> Address <br /> Owner's Name <br /> D /fp 9 Address 1 O-r- J, L.1LL/AAI IWIf License No- y Phone �/G�' 3$7 <br /> Contractor WELL REPLACEMENT CJ DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ --rte_— .T .,� OTHER ❑ l <br /> P TALLATION ❑ — SYSTEM REPAIR❑ ' <br /> SEWER LINES ��— DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TAN OTHER WELL PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL PROBLEM Dia. of Well Casing <br /> Bottom `E1 Manteca of Well Excavation <br /> ❑ Industrial ❑ Open Type o sing Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack [I Tracy Type of Grout <br /> ❑ Other ❑ Delta Depth of Grout <br /> ❑ Public Surface Seal Installed by <br /> 1-1 Irrigation __Approx. Depth ❑ Eastern State Work Done--- <br /> i e of Pum _�-- H.P. <br /> Repair Work Done ❑ Type p Sealing Material (top 501 <br /> I Well Destruction ❑ Well Diameter Filler Material (Below 50'1 <br />! Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION avail available ne200 feet.) <br /> if public sewer is <br /> `tOther <br /> installation will serve: Residence 1. Commercial—k-, <br /> Number of living units: _�— Number of bedrooms Water table depth <br /> kCharacter of soil to a depth of 3 feet: Capacity— No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg r� : Method of Disposal <br /> r � <br /> PKG. TREATMENT PLT. F1Pro Property Line <br /> Distance to nearest: Well Foundation p y <br /> Total length/size <br /> LEACHING LINE ❑ No. &itength.of lines Foundation Property Line <br /> FILTER BED ElDistance to nearest: Well <br /> i <br /> Size Number <br /> SEEPAGE PITS El Depth Property Line <br /> SUMPS ❑ Distance to nearest: Welf <br /> Foundation <br /> I <br /> 4. <br /> DISPOSAL PONDS ❑ <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 regulations of the San Joaquin Local Health District." work for <br /> Home owner or licensed manne9anot <br /> s to become mfe subjecies the t workman s compensation laws rtify that in the oof California."Contractor'stfiui g'or sub-cont acting signaturermit is issued, I <br /> employl employ any person in suchpersons subject to workman's compensa- <br /> t certifies the following:"1 certify that in the performance of the work for which this permit is issued,I shall employ <br /> I tion laws of California." <br /> The applicant must call for all required inspectI ns. Complete drawing on reverse side. <br /> Title: Date- <br /> Signed <br /> - FOR DEPARTMENT USE ONLY 1 <br /> I <br /> f <br /> Date r 2 Area <br /> Application Accepted by _ �{ r Date S�0 <br /> Pit or Grout Inspection b <br /> Date�� Final Inspection by <br /> Pit or or Grout inspection beY <br /> Additional Comments: <br /> ❑ Stk 466-6781 .❑ Lodi 369-3621 L3 Man 823-7104 on <br /> 835 6385 t <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazerton Ave., P.O. Box 2009, Stk., CA 95201 <br /> K RECEIVED BY DATE <br /> PERMIT"NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED SH <br /> �°. <br /> INFO <br /> +EH 1324(REV.1/a sl _ <br /> EH 14-28 - - <br />