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' APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made <br /> to the San <br /> Co aquiunty Ordinance Na. 549 for sewage or is application is <br /> District for a ealthpermit <br /> 1862 for cwell1pump t and/or install <br /> nd the Rules and herein <br /> Regulations of tlhe San Joaquin <br /> made in compliance w <br /> Local Health District. <br /> 33 3 � S9c Ao r city _ Lot Size PM <br /> .lob Address t <br /> d �'7 Phone <br /> y .?/�T�'*£,L� Address <br /> Owner's Name _ <br /> rid !f S"c1 j,r'LO/ License No. Z�.4 Phone <br /> Contractor <br /> AWIR,f'o V-f4e—f i Address <br /> TYPE OF WELL/PUMP: NEW WELL 71 WELL REPLACEMENT LJDESTRUCTION ❑ <br /> PUMP INSTALLATION E) PROP. <br /> REPAIR L1 OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> _ <br /> DISTANCE TO NEAREST: SEPTIC TANK PITSISUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> -..._.- <br /> INTENDED USE TYPE OP WELL PROBLEM AREA ;CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial LI Open Bottom ❑ Manteca Dia. of Well Excavation specifications <br /> ❑ Gravel Pack ❑ Tracy .Type ofCasing <br /> ❑ Domestic]Private .` Type of Grout--- <br /> ["I <br /> rout - .� <br /> I-] Other f ❑ Delta Depth of Grout Seal <br /> f`1 Public - <br /> I i Irrigation _.Approxi Depth I 1 Eastern Surface Seal Installed by <br /> H P State Work.Done-_ <br /> Repair Work Done 12 Type of Pump <br /> . <br /> Sealing Material ltop 50'1 <br /> Well Destruction ❑ Well Diameter A <br /> Depth Filler Material I8elow 601 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITI DESTRUCTIO septic system permitted if public sewer is <br /> t available within 200 fee1.1 <br /> Installation will serve: Residence Commercial_ Other A1411- 4W l <br /> Number of living units: Number of bedrooms Wafer table depth <br /> Character of soil to a depth of 3 feet:} No'. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ property Line <br /> Distance to nearest: Well Foundation <br /> 1 <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines property-Line <br /> FILTER BED ❑ Distance to nearest: Well w- -Foundation�� --�-- 3 <br /> f Number <br /> SEEPAGE PITS l 1 Depth Size PropertyLine <br /> SUMPS Ll Distance to nearest: Well Foundation <br /> DISPOSAL PONDS E]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, an <br /> rules and regulations of the San Joaquin Local Health D3trict. <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 /> i' employ any person in such manner as to signature <br /> become.subiect to workman's compensation taws of California." Contracersons1lsubject to ong or sub �kmantlsgompensa <br /> € certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ p <br /> 1 tion laws of California." t <br /> The applicant must for all re uired in ctions. Complete drawing on reverse side. 3 Y 2 �Q <br /> Title: f Date: <br /> Signed X .... <br /> ` FOR DEPARTMENT USE ONLY � r 3 <br /> Date Area <br /> Application Accepted by <br /> + sp ion by <br /> Date <br /> Date Final-Ih <br /> Pit or Grout Inspection by <br /> ` "-Tc-�Kt <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 C Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services,1601:E. Hazelton Ave.},P.O. Bax 2009, Stk., CA 95201 <br /> F f <br /> FEE CK RECEIVED BY DATE PERMIT NO. <br /> AMOUNT DUE AMOUNT REMITTED SH <br /> INFO f <br /> rJ3-a3 <br /> ��07 -� <br /> +.EH 13-24[REV.t/n 5] «- �'"^3S 5 l� e< _9 <br /> r EH 14-26 <br />