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APPLICATION FOR.PERMIT J r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT pERh1ST N0. y j� 3 <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781- . DATE ISSUED Pd <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> ermit to <br /> l the <br /> rein <br /> Application ThiseaeblYice eoroishmad'eninocompliancelwithlth SanDJoaqucin CountypOrdinance cNo, 549tfordsewagesorlNo. 1862rforewell/pump <br /> described. PP ,. <br /> and the Rules and,Regulatiens of the an oaquin Loc 1 Health district. <br /> SYn Subdivision N me <br /> Job Address r�-Wp� ( Phone <br /> Address — a <br /> Owner's Name 60 Phone <br /> Contractor's N <br /> License No. < <br /> p9 ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP WORK: NEW'WELL '' <br /> AL <br /> PUMP INSTLATION ❑ SYSTEM REPAIR ❑ OTHER Ljt <br /> ►,DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK 1I��_� SEWER LINES PITS/SUMPS <br /> FOUNDATION l <br /> AGRICULTURE WELL �_ OTHER I4FLL <br /> � <br /> INTENDED USE TYPE,OF WELL PROBLEM AREA CONSTRUCTION <br /> SPECIFICATIONS <br /> +. <br /> Mantecaa Dia. of,Well Excavation <br /> Industrial ❑open:Bottom ❑ - a ; , f V <br />€ Rr Tracy Diay. of_ <br /> Domestic/Private []Gravel Pack❑___ _ . _ <br /> u <br /> Public - T❑Other ❑Delta Type of Casing <br /> ❑ <br /> Irrigation Approx. ❑Eastern Specifications <br /> Depth s 4`Oe pt <br /> of Grout seal <br /> ❑ Cathodic Protection ( ti P , . <br /> ❑Geophysical Type_of Grout ti 5; <br /> Surface Seal Installed by <br /> ❑Other k ` <br /> ! T e of Pump H.P. State Work Done <br /> Repair Work Done ❑ Type <br /> Sealing Material (top 50') <br /> Well Diameter ✓ S <br /> Well Destruction ❑ Filler Material (Below 50')'� <br /> Depth - <br /> ❑ REPAIR/ADOITION No septicitank or.seepage pit <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION permitted if public sewer is <br /> available within 200 feet.) <br /> Installation Wiil serve: Residence _� Commercial Other Lot sii , N <br /> �. t <br /> Number of living units: Num er o bed oms — Water table depth r <br /> l Character of soil to a depth of. 3 feet: f C(a <br /> Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg f Disposal <br /> 1 --f,GaPac ity — --� Method o f� <br /> PKG. TREATMENT PLT. ❑ Type/Mfg ;`, �� "- Property Line <br /> SEWAGE SYSTEM <br /> Distance to nearest: Well F,oundatton ( \^ <br /> DESTRUCTION-" 12 <br /> ,_ Total l�ngth/size rzr <br /> LEACHING LINE No. &`Cength;of lines f Q Property Line �_-�_ <br /> F <br /> FILTER BED ❑ Distance to neares_t: . Well oundation_�,,,,, <br /> �� ��� _� <br /> Depth Number <br /> Size — <br /> SEEPAGE PITS _ _ Foundation —Ia— Property Line � <br /> fSUMPS ❑ Distance to nearest: Well <br /> DISPOSAL PONDS ❑ <br /> S hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county <br /> t. <br /> statees and ulations certifythatalth Dt to wor <br /> erformance of the work for which this <br /> permit is issued, I shall not employ any person in such manner as to become subjact to workmank compensation laws of California,"i <br /> Contractor's hiring or sub-contra <br /> hall employ9personsusubjectltoeworkmano slbompensationrlaws oftify aCalifornithe aerformance of the work for which <br /> this permit is issued, <br /> The applicant st call f all required inspections. Complete drawing on everse side. Date:a <br /> Title: + <br /> Signed X <br /> FOR DEPARTMEIT USE ONLY ❑ Stk 466-6781 <br /> Area <br /> Applicat on Accepted by Lodi 359-3621 <br /> Additional Comments: Date ❑ Manteca 823-7104 <br /> Pit or Grout Inspection``b Date ❑ Tracy 835-6385 <br /> Final Inspectidn by <br /> 'i <br /> Applicant - Return all copies) o: E vironmental Health Permit/Services 1601 E. Hazelton Rve., P.O. Box 2009, St k., �A 952 <br /> RECEIVED 8Y DATE PERMIT NO. <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED <br /> INFO <br /> 10/82 504- ` _rte✓ <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />