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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZES TON AVE., STOCKTON, CA <br />` Telephone (209) 466-6781 , <br /> PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) ; <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereiri described.TMs application is <br /> yr No. 1862 for well/ and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage <br /> Local Health District., ,+a,,.,�$t f <br /> City Lot Size C ' PM <br /> Job Address �- <br /> ,ld <br /> " Owner's`Name <br /> VlljyL¢ 7y -e- �e -' Address -4— <br /> Address 71, License No. ..-.f Phone <br /> Contractor _ ""- <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑, t <br /> DISPOSAL FLD. <br /> DISTANCE TO NEAREST: SEPTIC TANK .SEWER LINES <br /> PROPr LINE -' <br /> FOUNDATION 'AGRICULTURE WELL OTHER WELL— <br /> INTENDED <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 11 industrial ❑ Open Bottom CJ Manteca -Dia-of Well'EXcavation Dia. of Well Casing <br /> 4 Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack Ll Tracy Type of Casing <br /> ❑ Delta Depth of Grout Seal Type of Grout <br /> I ❑ Public ❑ Other _ <br /> EJ.irrigation --Approx. Depth ❑ Eastern Surface Seal Instalied,by <br /> Repair Work Done ElType of Pump H.P. ^"-State-Work Done` <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> I `. Depth Filler Material (Below 501 - --- 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11PAIR DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> avails le within 200 feet. <br /> �Installation will serve: Residence Commercial Other �� <br /> Number of living units:---L Number of bedrg3ms , � <br /> Water table depth <br /> Character of soil to a depth of 3 feet: , <br /> SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> �- is Total lengthlsize -1 <br /> LEACHING LINE No. & Length of lines - <br /> FILTER BED ❑ Distance to nearest: Well Foundation's'lb Property Line — <br /> s <br /> SEEPAGE PITS Depth i Jn Size 53 <br /> Number <br /> SUMPS <br /> ❑ Distance to nearest: Well .3ID-0 f Foundation.�� Property Line } <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. <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 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 applicantt call for all re 'ed inspections. Complete drawing on reverse side. <br /> 1 Date: 7 —30 !4 <br /> Signed Title: <br /> FOR DEPARTMENT USE ONLY <br /> -���� Date r Area lJ <br /> Application Accepted by <br /> 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 835-6365 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE CK RECEIVED 8Y DATE PERMIT"N0. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH ! <br /> +EH13-24(REV.1/85) 7'� �Q� i ��1/ 1p � <br /> EH 14.28 <br /> . a <br />