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I. l <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL'1ON AVE., STOCKTON, CA <br /> Telephone (200) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Jcation is <br /> o quin Local Health District for a peoiNo, 1662torcwell/ u and/or <br /> instal <br /> t wore nd Regulationprein s of he San.Thris g Joaquin <br /> Ppm.(/ ., <br /> made in compliance with San Joaquin County O ce No. 549 q s�4v�� r <br /> Local Health District, (� <br /> A . !W' PM <br /> `� C p City Lot Size 1 <br /> Job Address ` V 4 f / SID <br /> Phone U U D <br /> Address <br /> Owner's Name �`� O �/�2 <br /> Contractor Address <br /> 112 <br /> License No. �'" �Phone_ / <br /> TYPE OF WELL/PUMP: N€ WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION L) SYSTEM REPAIR ❑ OTHER El <br /> IE ER LINES DISPOSAL FLD. POOP, LINE <br /> l DISTANCE TO NEAREST: SEPTIC TANK <br /> FOUNDATION RICULTURE WELL OTHER WELL ?ITS/SUMPS w <br /> l <br /> S AREA CONSTRUCTION SPECIFICATION <br /> INTENDED USE TYPE OF WELL PROpia. of Well Casing <br /> r <br /> L] Industrial Li open Bottom En] M nt a Dia- of Well Excavation <br /> tType of Casing Specifications <br /> ❑ Domestic/Private f,"❑ Gravel Pack © racV Type of Grout = <br /> I (`l Public <br /> fl Other Delta Depth of Grout Seal <br /> _,_Approx': Depth I Easter Surface Seal Installed by <br /> I I Irrigation ,— State Work Done <br /> Repair Work Done ❑ ,Type of Pump H.P. <br /> Well Destruction ❑ -Well Diameter Sealing Material (top 50'1 v <br /> Depth . ;,I Filler Material 18elow 50.1 <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRIADDITION l I DESTRUCTION I I aNailabpe'w Thin 200 feet.)System ed if public sewer is Q <br /> 4 5 Y <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Number of bedro r Water table depth <br /> Character of soil to a depth of 3 feet. A No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Cap rty <br /> Method of Disposal <br /> PKG. TREATMENT PLT- ❑ "k Property Line t <br /> Distance to nearest: `" Well Foundation <br /> 1 <br /> LEACHING LINE ❑ No. & Length of lines <br /> r Total length/size <br /> I ❑ Distance to nearest: ti Property Line <br /> FILTER BED i <br /> SEEPAGE PITS I 1 Depth <br /> r Size mbar <br /> SUMPS ❑ Distance tone est: Well <br /> oundation � Property Line <br /> # w <br /> DISPOSAL PONDSstate laws, an <br /> ❑ <br /> Y hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, <br /> rules and regulations of the San Joaquin Local Health District. <br /> e following: '9 certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies th <br /> ct to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> employ any person in such manner as'to become subje <br /> certifies the following: "I certify that Wthe performance of the work for which this permit i ssued,!shall employ persons subj t to workman's compensa- <br /> tion laws of California." r <br /> The applicant ust tail f r required i spections. Compleie-diawing on reverse side. <br /> Tide: <br /> Date: t <br /> i <br /> � �- <br /> Signed X � <br /> l FOR DEPARTMENT USE ONLY <br /> Area <br /> �.. Date r <br /> Applicat a Accepted by <br /> final Inspection by hate <br /> < ` Pit or Grout Inspection b Date <br /> Additional CommentsY <br /> ❑ Stk 466-6781_ ❑ Lodi 369-3621 ,, Cl Manteca 823-1104 O Tracy 835-6385 <br /> Applicant "Return alf copies tot Environmenf11Health PPermit[Services 1601- . Hazelton Ave., P.O. Box 2009, Stk., CA 95201, <br /> CK <br /> { x FEE` AMOUNT DUE g: AMOUNERE TTED CASHjRECEIVED BV RATE PER�MiyT}}NI�O�.f.INFO °� y04�-/ ,7of 02` ! 6 <br /> F+.EH 13-24 IREV:-i r'K 3� ` 1 .•.., - <br /> ' FH 14.26 <br />