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APPLICATION FOR PERMIT ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE,-TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> is (Complete in Triplicate) <br /> cation is <br /> Application is Iwi . This <br /> th r h e tothe San Joa <br /> Joaquin Cou�ty Ordinalpermit Health District for a install <br /> Ordinance No.549 for sewage or No. 1862 for wellipump and the Rules and IR Regulations of the San l Joaquin <br /> made in comp <br /> Local Health District. <br /> 1 City Lot Size PM <br /> Job Address ^�f�p <br /> r / G <br /> �!Y�r� J �~ Phone <br /> Owner's Name Address,` ze� � . <br /> II GLicense No. �� Phone <br /> Contractor I �Iy f*S a4dtlress_ <br /> 1 TYPE OF;WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATIO <br /> jSTEM REPAIR ❑ OTHER ❑ <br /> NI=� AL FLD. PROP. UNE <br /> DISTANCE TANK SEWER LINES DISPOSAL <br /> E TO NEAREST: SEPTIC E <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> Domeltic/Private I��Gravel Pack EJ Tracy Type of CasingJFJ ` <br /> n Delta Depth of Grout Seal Type of Grout <br /> M Public [t l Other _ <br /> _Approx. Depth 1 I Eastern Surface Seal Installed by <br /> I I irrigation State Work Done <br /> e of Pum H.P. - r- <br /> Repair Work Done ❑ TYP p r <br /> Sealing Material )top 50'1 J -- <br /> Well Destruction ❑p�VITe�IE�Diameter' <br /> ep-th � , 1� Filler Material (Below 50'! <br /> E OF SEP_71G._W..ORK:�NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION I I(Nailaile`wtiin"200 festem et.) if public sewer is CJI I <br /> TY, 1 <br /> I . %F �. W <br /> installation will serve: Residence C mmercial_ Other <br /> ' �`N `rrrhar o bedrooms 4 <br /> Number of of living units.. t - Water table depth <br /> r <br /> Character of soil to a-,depth�`3et: a No. Compartments <br /> 71 <br /> SEPTIC TANK i LlType/Mfg k Capacity <br /> r L--t Method of Disposal [' <br /> TREATMENT PLT. ❑ <br /> Distance to nearest: =—WeH Foundation Property Line � <br /> r <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> I <br /> Size _ Number <br /> y SEEPAGE PITS I I Depth Property Line <br /> SUMPS ❑ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ <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 /> r 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 /> 4 employ any person in sf the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature <br /> I certifies the following: certify that in the performance o <br /> 1 tion laws of California." � <br /> The appli�ant mys a(I, quired � ns. Complete drawing on reverse side. <br /> Signed <br /> Title: Date: <br /> .Z����- <br /> I ] FOR DEPARTMENT USE ONLY <br /> I p �/ Date Area <br /> ! Application Accepted by _ <br /> I Pit or Grout Inspection by <br /> Date_.��- Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2{309, Stk., CA 95201 ^ <br /> ff3MMrH! <br /> K RECEIVED BY DATE PERMIT'NO. <br /> ASH /—W�y37EH13-24IREV.�/nsl <br /> EH 14-2e �' <br />