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i <br /> APPLICATION FOR PERMIT 13: 00 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT k <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> _PERMIT_ EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> /or install the <br /> rk herein <br /> . This <br /> cation is <br /> madApplication <br /> ec nticomphtice wmfi Sande o the Joagsan Coungtyr0 ordinHealth District for a ance No.549 for sewage o permit <br /> No 1962 forcwelUpump and the Rue and Rep�auons of t1 a San Joogtrin <br /> Local Health District. <br /> ,e IIIII City k k4—d- Lot Size— PM _ <br /> Job Address <br /> ` _ Phone — <br /> Owner's Name _._ alt Address <br /> Contractor—. dress <br /> License No.�z4m Phone _ <br /> TYPE OF WEI Li PUM NEW WELL C1 WELL REPLACEME ❑ DESTRUCTION C! <br /> PUMP INSTALLATION fl SYSTEM REPAIR G OTHER F1 <br /> SEWER LINES - — DISPOSAL FLD.--— PROP. LINE _— <br /> DISTANCE TO NEAREST: SEPTIC TANK _' _. <br /> FOUNDATION ` — AGRICULTURE WELL OTHER WELL PITS/SUMPS - <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LTia of Well Casing _ <br /> ❑ Manteca Dia. of Well Excavation <br /> L_I Industrial U Open Bottom _ — <br /> -= <br /> Domestic/Private Ll Gravel Pack G Tracy <br /> Type of Casing Specifications <br /> I"1 Public <br /> r Other i-I Delta Depth of Grout Seal Type of Grout -- .------ <br /> Irrigation —.Approx. Depth I ! Eastern Surface Seal Installed by - <br /> Repair Work Done L' Type of Pump _ H.P. — State Work Done_ -- <br /> 1 I <br /> Well Destruction L' Well Diameter _ Seating Material trop 50'I --- <br /> Depth Filler Material[Belo I - t <br /> f 00 <br /> j TYPE OF SEPTIC WORK: NEW INSTALLATION I I IR I -DESTRUCTION I avail hlterw thin 200 feet.►i(public sewer is <br /> Installation will serve: Residence— Commercial — Other <br /> Number of living units: --N- Number of bedrooms _ - r4 > <br /> Character of soil to a depth of 3 feet: Water table depth- <br /> SEPTIC TANK ❑ Type,`Mfg _ — <br /> Capacity I __ No. Compartments <br /> `PKG. TREATMENT PLT. ❑ 1 — Method of Disposal _ <br /> Distance to nearest: Well _ -Foundation I Property line <br /> f EACHING_LfNE I-; No. & Length of lines ._ Total length/size <br /> F BED 17 Distance to nearest: Well Foundation tL.— Property Line - <br /> dHH <br /> AGE �tl l�.Depth Size {���11 � ���Ntulmber <br /> SUMPS L1 Distance to nearest: Well��LtC Foundation��1LT_ Property Line <br /> DISPOSAL PONDS l <br /> I 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. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued. I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify that in the peAormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant t c r req Date: <br /> inspections. Co eta drawing on re -s side. — ` <br /> Signed X__C % _ Title: _ <br /> F EPARTMENT USE ONLY ^�� //�/ <br /> 1' Date '97 .— Area ; . <br /> Application Accepted by , <br /> zS, <br /> Pit or Grout Inspection by --t Date Final Inspection by — Date <br /> i 4 a r <br /> Additional Comments:- <br /> 0 Stk 4666781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835.6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk-, CA 95201 <br /> ff[I CK¢ RECEIVED BY DATE PERMIT NO. <br /> UNTDUE AMOUNT REMITTED CASH <br /> EH 13-24(REV.t%n�i '710 O-1 <br /> EH 1426 <br />