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j' APPLICATION FOR PERMIT <br /> r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEILTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> G' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> all the work <br /> ribed.This <br /> cation is <br /> Application is I ance wmade <br /> th Sanvthe Joaquin County Ordinance No.Districtn Joaquin Local Health 549 for sewage orpermit <br /> No. 1862 for wellapump and the Rules and IRegulativns of he San i Joaquin <br /> .. made in comp � <br /> Local Health District...,,, ,..-, p _ � M ur /l�-7 <br /> # f✓/✓� 1L City 1 t I <br /> Lot Size <br /> Job Address l P ��r f <br /> � Phone <br /> Owner's Name <br /> l l. W I l��s N Address �2IS/'h <br /> L�+. �� License No, Phone <br /> Contractor's Name o� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ v <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 13 <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES AGRICULTURE WELL <br /> FOUNDATION OTHER WELL_ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> i C3Industrial [IOpen Bottom LlManteca Dia. of Well Excavation <br /> Type of Casing {� Specifications <br /> ❑ Domestic/Private Ll Gravel Pack El Tracy g Type of Grout S� <br /> ❑ Other ❑ Delta Depth of Grout Seal <br /> ❑ Public . ,P. �.' <br /> ❑ Irrigation --Approx. Depth r ❑ Eastern Surface Seal Installed by <br /> p- H.P. <br /> State Work Done <br /> Repair Work Done ❑ Type of Pump• <br /> Well Destruction ❑ Well Diameter r Sealing Material (top 501 <br /> Depth <br /> = Filler:Material (Below 501 . <br /> i TYP OF SF,2IIC WORK: NEW INS AL TIG © REPAIR DDITION ❑ DESTRUCTION S vailabpe(withm 20Q permitted if public sewer is <br /> R l�/N6 01-ID �` s�s� �. ef <br /> ' Instalfation will serve: Residence — Commercial Other }�� (.._1 C� V� j 7 �`� &J,2�"- _ <br /> f y � G <br /> Number of living units: Number of droo Water table depth <br /> Character of soil to a depth of 3 feet: <br /> (� No. Compartments <br /> SEPTIC TANKType/Mfg Ca aAcity��a <br /> `I� IG Method of.Disposal <br /> PKG. TREATMENT PLT. ❑ ZTF-L <br /> �� / Pro ert LineDistance to nearest: tweli ndation Property <br /> ( <br /> LEACHING LINE ll No. <br /> No. & Length of lines - Property Line <br /> FILTER BED ❑ Distance to nearest: <br /> Well F ation <br /> } z A , > <br /> _ SEEPAGE PITS - ❑+ Depth i. M Size Number <br /> I't1 SUMPS ` }r ❑ Distance to nearest: Well✓ Foundation Property Line <br /> DISPOSAL PONDS ❑ 3 f X #4 "� <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, an <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 sui h manner as to become subject to workman's compensation laws of California." Contractors 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." 3' <br /> The appli nt mug call for.all re ui inspections Complete drawing on revs side. �� <br /> r �- Title: <br /> .-. _ Date: <br /> Signed <br /> FOR DEPA MENT USE ONLY �,1 <br /> Date - Area '° <br /> Application Accepted by sj 7 � <br /> Date Final Inspection by"- Date L 7 <br /> Pit or Grout Inspection by r <br /> Additional Comments_, ❑ Manteca 823-7104 racy 835-6385 <br /> ❑ Stk 466-6781 N ❑-Lodi 369-3621 y_ <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 :Hazelton'Ave., P.Q. Box 2009, Stk., CA 95201 <br /> AMOUNT;DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT`NO. <br /> FEE CASH <br /> INFO x <br /> + E1413-24(REV.10!63) <br /> EH 1428 <br />