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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> .10ERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> rl <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> e or No. 1862 for well and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for sewag <br /> Local Health District. <br /> `l `'1 � � Ci City C r`9t�'2 Lot Size PM <br /> Job Address Ei Phone 3 <br /> �q,�G�1Address <br /> Owner's Nam <br /> /�r� �v P©, 1OJCZl License No.1iZ -6 Phone <br /> Contfact0,/ "/E- �'G�T1G Address DESTRUCTION 171TYPE OF WELL/PUMP: _ NEW WELL EJ _ WELL REPLACEMENT ❑ <br /> SYSTEM REPAIR ❑ OTHER 171PUMP INSTALLATION IJDISPOSALFLD. - ` PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES PlTS1SUMP5 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` <br /> — --- Dia. of Well Casing T <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> Tracy <br /> Type of Casing <br /> Cl Domestic)Private D Gravel Pak 0 Delta Depth of Grout Seal Type of Grout <br /> i i Public C1 Other - <br /> o.� A proz Depth i I Eastern Surface Seal. installed by <br /> € ! I Irrigation — p State Work Done <br /> + Repair Work Done El Type of Pump H.P. <br /> iSealing Material (top 501 <br /> , <br /> Well Destruction ❑ Well Diameter <br /> Filler Material (Below 501 <br /> 'i <br /> stem <br /> TYPE OF SEPTIC WORK: NEW INS4 ALLATION REPAIR/ADDITION I I DESTRUCTION I I (Nailabperwithin 200 feet.itled if public sewer is <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: aaCompartments <br /> SEPTIC TANK a Type/Mfg L tree I Capacity �f . <br /> j <br /> Method.of Disposal_ <br /> PKG. TREATMENT PLT. ❑_ ,,._ Property Line <br /> T Distance to nearest: Well Foundation p Y <br /> 1 <br /> LEACHING LINE ' No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance tonearest,. Well <br /> Foundation` i Property Line <br /> r <br /> SEEPAGE PITS l I Depth r. Size—_ ' Number <br /> 1 <br /> SUMPS I f. Distance to nearest: Welt <br /> Foundation; Property Line <br /> # DISPOSAL PONDS ❑ r _' f <br /> I hereby certify that 1 have prepared.this application and that the work will tie don`in acco�rddance with San Joaquin county ordinances, state laws, and <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 s1.ignature not <br /> employ any person in such manner as to become subject to workman's compensation laws of Califainia." Contractor's nslring sub ecrsub <br /> t to wo�kmant�sgCompensa- <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,i shall employ p t <br /> tion laws of California." <br /> f{ The.applican call all require ctions. Complete drawing on reverse side. /� <br /> � ' Title: — <br /> Date: Z <br /> Signed ; <br /> FOR DEPARTMENT USE ONLY <br /> } Date I �� Area E <br /> Application Accepted by . <br /> Pit or Grout Inspectio y <br /> Daie .Final Inspection by Date Q <br /> :: <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ; ❑ Tracy t335-6385 <br /> ApplicantReturn all copies to: Environmental Health. Permit/Services 1601 CHazelton-Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AM©_ 11NT REMITTED CK FI RECEIVED BY DATE r' PERMIT!'NO. <br /> I <br /> INFO 00 �Y7 <br /> + EH 13-241REV..i/H51 <br /> EH 14-28 <br />