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f <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA } <br /> Telephone (209) 466-6781 <br /> IPERMIT EXPIRES 1,YEAR FROM DATE ISSUED <br /> rr (Complete in Triplicate) the <br /> ealth District for a p n described.This )(cation is <br /> all <br /> Application is hereby made to the SanJo Cou ty ordinance No.549 for sewage or permit <br /> 1862 forcwell/pump lor and the Ruoles andrk Regulationsof the San Joaquin <br /> made in compliance with San Joaquin x N <br /> Local Health District. , <br /> City Lot SizeQ LL ud_ PM --- f <br /> Job Address Q R <br /> �^l . Phone <br /> r,} Address 1/ 4 <br /> Owner's Name f7 (fig-S <br /> License Ko. 2 a _76 Phon <br /> 3 v� <br /> ' Address (/�} <br /> ContrDESTRUCTION <br /> act r WELL REPLACEMENT ❑ ❑ f ll <br /> TYPE OF WELL/PUMP:. NEW WELL ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ A, <br /> PUMP INSTALLATION.—IJ_, .- DISPOSAL FLQ. PROP. LINE <br /> SEy�-LJNES —� — <br /> DISTANCE TOINfAREST SEPTIC TANK AGRICULTURE WELL WELL PITSISUMPS <br /> r;. <br /> f - FOUNDATION <br /> ' ? TYPE OF WELL PRO13L� EM AREA CONSTRUCTION"SPECIFICATIONS <br /> INTENDED USE Oia�of Well Casing <br /> '© Op Dia. of Well Excavation <br /> EJ Specifications <br /> I ❑ Industrial 'i/ en Bottom ' Type of Casing <br /> 0 Domestic/Private '�i<E ❑-Gravel Pack ❑ Tracy �; j Type of Grout <br /> i C:i-Delta ,Depth of Grout Seal <br /> Li Public -�-n-Other Q.- ... r <br /> i Surface Seal Installed by <br /> I I Irrigation �_Approx. Depth I ! Eastern State WarDone , <br /> t I H.P. <br /> Repair Work Done L3 Type of=Pump <br /> �`-= - = Sealing-Material )top 50'1 ' <br /> j Well-Destruction-�• ❑- Well-Di ameters=— <br />{P Depth I\ ller Material (Below l <br /> I DESTRUCTION l 1 (No septic system permitted if public sewer is <br /> TYPE OF SEP71C'N70RK: NEW INSTALLATION {.� REPAIR ADITIbN .� available within 200 feet.) <br /> Commercial-----Other <br /> I <br /> installation will serve: Residence <br /> Number of living units: Number f edra s /-.D <br /> t 1 Water table depth <br /> Character of soil to a depth of 3 feet: :,r r Capacity— No. Compartments <br /> i SEPTIC TANK 0 Type/MfgMethoii"of'Disp`dsal " <br /> PKG. TREATMENT PLT. ❑ yProperty Line <br /> Distance to nearest: Well foundauon,�— 7 <br /> x <br /> t=- Total length/size t . <br /> No. & Length of <br /> LEACHING LINE tines / . <br /> rd <br /> Founation Property Line <br /> FILTER BED ❑ Distance to nearest: Well 1f �- . <br /> r . . tt J. <br /> Number <br /> Size <br /> l DepthLine `". <br /> SEEPAGE PITS r Foundation /d* Property L e <br /> SUMPS L-1 Distance to nearest: Well <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that l 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 /> g' work for <br /> Homnot <br /> e owner or licensed h mangle gas torbecome subject Ito workman'srtcoythat in mpansation lawsoof Califon ahe Contractor'srhiringrs permit is issued,or sub.-contracting lsignatu e <br /> employ any person in such <br /> certifies the following: u certify that s the performance 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 applica ust call r all squired inspections. Complete drawing on reverse. 't� <br /> Title: F' 11 Date: �Q <br /> .signed X ' <br /> t FOR D ARTMENT USE ONLY <br /> Date Area <br /> r Application Accepted by� Final Inspection by Date <br /> r Grout Inspection by <br /> bate � <br /> Additional Comments: <br /> anteca 823-7104 ❑ Tracy 835-6385 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ M <br /> Applicant Return all copies to: Erivironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2!)09, Stk., CA 95201 <br /> iCK RECEIVED BY GATE PERMIT NO. <br /> FEE AMOUNT DUE AMO T REMITTED CASH <br /> INFO <br /> + EH 13-24{REV.I/n 51 <br /> EH 14-2e p <br />