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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> TW678] <br /> Telephone (209) 466 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDL� , d7r <br /> (Complete in Triplicate? �p-n M /Q"7_&j <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install th work!herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for se age No. IB62 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. 6 �� <br /> Job Address CJIr�+` O (V✓�/I� f / ,G4y:V Cityrr Lot Size /aQ '`� PM <br /> Owner's Name W -7�qc r 4 e ie, Address562, +"' C'"''L)'�'y� {td�L J Phone <br /> Contractor "I�- '`"'�G' Address. l���r� O License No. Phone <br /> l <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> 'PUMP INSTALLATION ❑ SYSTEM RE AIR CJ , � <br /> OTHER �/(, BOe�.l�r <br /> DISTANCE TO NEAREST: SEPTIC TANK .�0B°f SEWER LINES 10 DISPOSAL-FLD. ' .�� PROP. LINE 414K/eS I <br /> FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1 <br /> C.Domestic/Private ❑ Gravel Pack" ❑ Tracy Type of Casing Specifications <br /> 1-1 Public Other f 1 Delta Depth of Grout Seal Type of Grout _ <br /> I I IrrigationApprox..Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done LliEpe. <br /> of Pump! 0 H.P. N 0y t; State Work Done_ <br /> V Well Destruction „ 0,1- 'Well Diameter uC ty Sealing Materia! (top 50'1 (l �. <br /> Depth1 !G! yC Filler Material (Below 50'1 <br /> YPE OF SEPTIC,WORK: . NEW INSTALLATION I I REPAIR/ADDITION I ] DESTRUCTIO I 1 {No septic system permitted if public sewer is— I <br /> available within-200 feet.) I <br /> Installations " rve: Residence_ Commercial Other ,a, •i <br /> Number of'living units. Number of bedrooms <br /> �'Characterr'of,5oil to a depth of Water table depth <br /> SEPTICGTANK`i LJType/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Cl ' Method of Disposal !� , <br /> Distance to nearest: Well oundation Property.Line <br /> o- I <br /> LEACHING LINE Cl No. & Length of lines I length/size <br /> FILTER BED "❑ Distance toynearest: Well Foundation Line <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS Cl Distance tp"nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Cl Ll <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 /> rules and regulations of..the San Joaquin Local Health Di%tiict. <br />\ Home own" leen 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 /> employ a person in s c nar as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature l <br /> certifie he following: ' certify t tin the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- <br /> tion la s of Californ' <br /> The app" an s c II for all a u" inspections. Complete drawingo ver de. <br /> Signed X_. Title: � Date: 7, !� <br /> R DEPARTMENT USE ONLY qq i <br /> Applicati8n Accepted by Date tY-^a Area ! <br /> Pit or Grout Inspection by Date Final Inspection by Date 4& <br /> t <br /> Additional Comments 127A zrGtit.�+t i <br /> ❑ Stk .466-6781 ❑ Lodi 36-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i <br /> EE AMOUNT DUE AMOUNT REMITTED CK <br /> /NCASH RECEIVED BY DATE PERMIT'NO. <br /> r.EH 13-241REV.t/n51 � rf <br />