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" APPLICATION FOR PERMIT " <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT I <br /> 1601 E. t-A:�ELTON AYE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> istrict ermit fora ppermit -anti/or install the work herein described. This appli <br /> Application is hereby made to the San Joaquin Local Health Dcation is <br /> made in compliance with San Joaquin County Ordinance Na 549 follSewage`or No. 12 for welltlp and the Rules and Regulations of <br /> Local Health District. ; �`""� '"^—•-# �^ <br /> { /v City Lot Size PM J <br /> Job Address t <br /> e <br /> 1 I �� <br /> ' S Phone <br /> Address <br /> Owner's Name <br /> Phone <br /> Address <br /> Contractor <br /> LAI- <br /> License No. <br /> NEW WELL .WELL REPLAC MENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELLIPUMP: - SYSTEM REPAIR ❑ • I OTHER ❑ <br /> I PUMP INSTALLATION , rr, �'a <br /> f— SEWER IVES `.ID1Sl?OS4L PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TA1VK _ _ f -- i pTHER WELL €� PITSISUMPS <br /> FOUNDATION � AGRICULTURE WELL <br /> i i s fh <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFifGAl Dia of Well Casing 6!/ YV <br /> ❑ Industrial ❑ Open Bottom © Manteca Dia. of-Well Ex-cavattiio'j <br /> T e of Gasig I Specifications — -sv <br /> Domestic/Private ,Gravel Pack ❑ Tracy yp -iL, —a S Tye of Grout <br /> t'1 Public f 1 OtF er L] Delta I Depth of Groutp <br /> .Seal S I p <br /> �Approx. Dept <br /> tern u� ce Seal. Installed by F <br /> I I Irrigation , H P ��j%i c-� State Work Done <br /> Repair Work Done D Type of Pump I, <br /> Sealin� Material ltop`5011i <br /> Well Destruction ❑ Well Diameter r <br /> _ Depth Filler Material (Below 50') ' <br /> ` TYPE OF SEPTIC WORK: NEW INSTALLATION { I REPAIR/ADDITION l I DEST fl�lCTION 11,aNailabpe1wthine200 fe tit`ed if public sewer is <br /> Installation will serve: Residence_ Commercial— Other <br /> I Number of living units: Number of bedrooms Water table depth <br /> I Character of soil to a depth of 3 feet: <br /> Capacity Na. Compartments <br /> SEPTIC TANK F1Type/Mfg Method of Disposal <br /> r PKG. TREATMENT P'LT. ❑ <br /> Distance to nearest: Well Foundation r y "}Property;Line <br /> 1 Notal length/size <br /> LEACHING LINE ❑ No. & Length of lines = t <br /> FILTER BED l ❑ Distance to nearest: Well i Foundation I Pro" tine <br /> kI Size I Number 3 I <br /> SEEPAGE PITS It Depth: 1 i i <br /> SLl Distance to nearest: <br /> Well Foundation {Proprt Line <br /> SUMPS <br /> r DISPOSAL PONDS 12I t f <br /> I hereby certify that I have prepared this application and that the work v ht-be dole in accordance with 5an';Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. 1 I <br /> Home owner or licensed agent's signature certifies the folio workman'srtcampe ify that Iat onln 1he aerformanA wsd -Calif o rniahelContractor sIh ri g'or sub-cont act nglsignatuore <br /> employ any person in such manner as to become subject 2 <br /> a ersons sub ec`t to workman's compensa <br /> certifies the following: "I certify that in the performance of the work for which this perit.is iss�e�("shall a ptoy p 1 <br /> tion laws of California." I — <br /> The applicantAl squired Complete drawing on rev/erse side:. ! g <br /> I vvv .��Titlle: !`Y Date:!` �'� `"� '�U <br /> Signed X <br /> FOR DEPARTMENT USE i0NLY <br /> ` Dete q f✓(10 Area <br /> Application Accepted by " ' <br /> 1: I i Date <br /> Pit or Grout Inspection by Rate Final Inspection by EE <br /> r <br /> i _ 1 <br /> Additional Comments: i <br /> ElStk 466 5781 D Lodi 369-3621 Cl Manteca 823-7104 ❑ Tracy 835-'6386 <br /> nvironmental Health Permit/Services 1601 E. Hazelton Ave VP.O. B5x`2009, Stk., CA 9520 <br /> Applicant--Return_all_coQies to: E1 <br /> t^ '� " kUs I� ft£CE1VED-By-- DATE =PE_FlMIV-NO:x <br /> FEE AT/IOIJNT DUE-----^�gIU_OUfTwH;EMITTD CA$ y <br /> INFO <br /> .1 C <br /> f <br /> �.EH 13C <br /> 20(REV.i/H 5S 1 '5- <br /> EH 14-28 ® <br />