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APPLICATION FOR PERMIT <br /> SAN JOAO.UIN,iOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE.,.STOCKTON, CA <br /> Telephone (209) 466-6781 r <br /> PERMIT EXPIRES 1 YEAR FROM-DA TEISSUED <br /> (Complete in Triplicate) <br /> .4gvc 4, + -construct and/or install the work herein described.This app <br /> 1lcation is <br /> Application-is hereby made to the San Joaquin Local Health District for a permit to cwelllpump and theRuleand Reg <br /> made in compliance with San Joaquin County Ordinance No.549 for,sewage or No. 1862 for Regulations V. <br /> of the San Joaquin <br /> Local Health District. <br /> yi - # . - City Lot Siz PM <br /> Job Address ., - - <br /> 2J�5 �, �� Phone <br /> Owner's Name <br /> Address / <br /> !� �fc PhoneJ"��� S ©,5 <br /> ,�L l d Address License No <br /> Contract f DE57Rt3CTION ❑ Y t <br /> L REPLACEMENT LJ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELSYSTEM REPAIR ❑ OTHER ❑ <br /> p. PUMP INSTALLATION ❑ s <br /> SEINER LINES ��— DISPOSAL FLD. PROP. LINE ' <br /> DISTANCE TO NEAREST: SEPTIC TANK > <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PiTSISUMPS t <br /> r � <br /> INTENDED USE; » TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS { <br /> �~ Dia. of Well Excavation Dia. of Well Casing <br /> 1. Industrial "St y. ❑ Open Bottom ❑ Mantecai Specifications <br /> 1' ❑ Domestic/Private v ❑Gravel Pack,- .w LlTracy� ��3 TYPe of Casing Type of <br /> ❑ Delta Grout <br /> Dept;of Grout Seal <br /> ❑ Public ti Other <br /> It _�pprox. Depth Z ,.❑ Eastern Surface Seal installed by ; <br /> ❑ Irrigation `s State Work Done <br /> Repair Work Done Ll Type of Pump ti �.� H-P• — T <br /> \)heli Destruction ❑ Well Diameter Sealing Material )top 50') Y <br /> Depth v/ ler_Material )Below 50'1 i <br /> TYPE OF SEPTIC WORK: NEW IN57ALLATION ❑. REPAI (,ADDITION' DESTRUCTION ❑ availablelwith n 20tern 0 permitted if public sewer is <br /> J <br /> r J <br /> Installation will serve: Residence l Commercial Other <br /> Number f living units: Number of dr ms _} .I Water table depth' 01 <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK 17Type/Mfg --7 Capacity <br /> ti t Method of Disposal <br /> PKG'ITREATMENT PLT. ❑' � � ► Pro rt Line <br /> Distance to nearest: Well ' Foundation ` Property <br /> d vTotai'length/size <br /> LEACHING LINE* 41k No• & 1 ength of lines ° - property Line <br /> ' ' e Foundation <br /> FILTER BED Os Distance to nearest: - Well = �.—_Pro <br /> pe <br /> #W =Sae-'-� Number_ <br /> SEEPAGE PITS 1100` Foundation _ Property Line— <br /> SUMPS { ❑ Distance to nearest: Well <br /> DISPOSAL PONDS Cl <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 /> 4 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, l signature <br /> shall not <br /> { employ'any person in such planner as to become subject to workman's compensation laws of California ploy ersonslring or subj subject t workman'Iscompensa- <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ pe <br /> tion laws of California." ,1 <br /> The applicant st call for all quire inspections. Complete drawing on reverse s e. <br /> t TiNe: Date: <br /> Signed X f <br /> G i FOR DEPARTMENT USE ONLY <br /> yDate Area <br /> Application Accepted by � (y <br /> ` _,-L Final Inspection by <br /> Pit r Grout Inspection by Date <br /> Additional Comments: <br /> 1 El 823-7104 - L1 Tracy 835-6385 <br /> D Stk 466-16-781 LD Lodi 369-362 <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 <br /> i. 44 <br /> I t ti <br /> 4 FEE CK RECEIVED 9Y DATE PERMIT'N0. <br /> r AMOUNT,DUE AMOUNT REMITTED CASH <br /> INFO 5 <br /> r EH 13-24 1 REV. <br /> EH 14-26 -- <br />