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APF+i.iCATi FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT j <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> '7E lephone 12091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED TIt <br /> I (Complete in Triplicate) <br /> n described, This <br /> cation is <br /> Application is hereby made to the San Joaqui O dlnalnHealthce Na.District49 for sewage or INo�1867 for well apump and the Ryles and/or install the work (Regulations of he San r Joaquin <br /> made in compliance with San Joaquin county I `u " <br /> Local Health District. <br /> C ty` 11 f`Lot Size PM <br /> Job Address <br /> ; .. � K, <br /> 1l � 4 Phone <br /> Owner's Name Address <br /> s ys• Phone <br /> 1111 1, 1A ddress «� License No. <br /> Contractor DESTRUCTION ❑ <br /> TYPE-OF-WELL/PUMP:�""'�` -ANEWWELL �--�- ---+-WELL REPLACEMENT ❑y" � <br /> - n X ^- OTH R_❑ <br /> P_UMP�NSTQLLATION_( r_-- SY_S_T,EM_REPAIR_❑ 7" <br /> ` -- DISPOSAL FLD._ 0� PROP. LINE <br /> r � SEWER LINES <br /> DISTANCE TO NEAREST: SEPTIC TANK � AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> FOUNDATIO <br /> s y N {.- �— <br /> r <br /> s- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial Open Bo <br /> [I Manteca Dia. of Well Excavation S ecifications J Do 'a ( 7Gravel Pack. ❑ Tracy i�Type of Casing STE � p <br /> 1 Depth of Grout Seal "��'� Type of Grout <br /> ' Public ❑._Other,.� ❑ Delta <br /> ._ M Ni <br /> Irrigation. t'�Approx.;Depth ❑ Eastern <br /> .,Surface Seal Installed by <br /> I Z State Work Done <br /> `Repair Work Done ❑ Type of Pumpl1�- k A <br /> Well Destruction ❑ Well Diameter ; Sealing Material (top 50'1 V k a <br /> PDepth Filler Material (Below 50'1 <br /> _4 <br /> TYPE OF SEPTIC WORK: NEW NSTALLATION L-1REPAIR/ADDITION El DESTRUCTION ❑ (No sep <br /> f e�with ne200 feetlt}ed if public sewer is <br /> Installation,willsAry ~Residence Commercial? Other <br /> Number of living units: 7Lf�(Number of bedrooms <br /> s� i Water table depth <br /> Character of s ioio to a depth of 3 feet. No. Compartments <br /> + - T-•--de Capacity <br /> y. SEPTIC TANK,; ❑�Yp /Mfg" Method of Disposal <br /> PKG TREATMENT PLT. ❑ Property Line <br /> Distance to" nearest: Well Foundation p V <br /> u Total length/size <br /> LEACHING LINE ❑ No. & Lengthiof lines <br /> s Property Line <br /> r h Foundation P rtY <br /> n FILTER`BED ❑ Distance to nearest: Well <br /> ENumber <br /> SEEPAGE PITS ❑ Depth Size Property Line <br /> nF s o Well Foundation <br /> ❑ Distance tnearest: <br /> SUMPS � ; <br /> �= DISPOSAL PONDS ❑ <br /> i 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 rer or license the San Joaquin Local Health District. <br /> � Home owner or licensed agent's signature certifies the following: "I cert to workman tify that in the perforrtiahce of the work for which this permit is issued, I signature <br /> she not <br /> tion <br /> of <br /> ceriifiesemploy ahe follpwiin ngisul certify that 16 the performance— In manner as to become <br /> —t <br /> he wok for which this permit is issued,f�sfiaH employ pe�sonsrrs lsubject to workman'sring or eompensa <br /> . . _. <br /> tion-laws of California."� ""�`� *� r <br /> The applicant m s call r all required inspections. Complete drawing,on r ver side. ` <br /> Date: <br /> �-- Title: <br /> Signed' iR <br /> FOR DEP TMENT USE ONLY p <br /> Date <br /> 1.2-146' •`Q ) Are <br /> Appli!tion Accepted�y r <br /> r Date l <br /> t .Pit or Grout Inspec#io <br /> Date �+ Final Inspection by <br /> d 'tonal Comments:) <br /> Stk 466-6781 Lodi 369-3621 ❑ Mante 823-7104 13 Tracy 835 6385 <br /> Applicant Return all copies to: Environmental Health PerTiit/Services 1601 E. Hazelton Ave., P.O. Box 2009,.Stk., CA 95201 <br /> CK RECEIVED BY DATE PERMIT"'NO. <br /> k l <br /> FEE <br /> DUE i AMOUNT REMITTED r CASH <br /> -7_ <br /> + EH 13-24[REV. <br /> EH 14-28 <br />