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—• APPLICATION FOR PERMIT <br /> a <br /> ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> HAZELiON AVE., STOCKTON, CA <br /> 1601 E. jR�'L1 QED <br /> Telephohe (209) 466-6781 <br /> PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> �f 2 b <br /> (Complete.in Triplicate) X988 <br /> mtwwv� <br /> bed.This application is f <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor instaN the �San Joaquin <br /> made in compliance with San Joaquin County�rdinance Nog foN° �2 for wjjlpump and the C�s <br /> Local Health District. �, }D .-T. ((f �[%`4�s� <br /> V4 PIGf r i i <br /> 4 :—, . City ,' Lot Size <br /> Job Address <br /> Owner's Name ress <br /> 7 Ph n `�✓ <br /> Address License No. <br /> Contractor <br /> TYPE OF W LL/PUMP: NE WELL WELL REP CEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATi3O L1 SYSTEM <br /> /REPAIR ❑ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK ,' SEWER LINES '1t�-- DTHERSWELLAL D P�SPSLIMPS. LINE � <br /> FOUNDATION ' AGRICULTURE WELL O <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> LJIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casin �� Specifications ' <br /> 14 }� <br /> Domestic/Private Gravel Pack © Tracy yp g a j yt, Type of Grout <br /> 1-1 Public 1 f Ot�r Ll Delta Depth of Grout Seal ��T; <br /> I I Irrigation �Approx. Depth I I Eastern Surface Seal Installed by <br /> k H P State Work Done _- <br /> l Repair Work Done El Type of Pump <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 f <br /> fff ssm pe <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION {'I REPAIR/ADDITION 1.1 DESTRUCTION I i availabllerwthin 200 feet.) if public sewer is <br /> j Installation will serve: Residence, Commercial Other <br /> f , <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: <br /> r Ca <br /> SEPTIC TANK D. Type/Mfg <br /> pacity No. Compartments <br /> Method of Aisposal <br /> t PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> 1 <br /> Number <br /> SEEPAGE PITS ( I Depth Size r <br /> SUMPS LZ Distance to nearest: Well Foundation Property Line <br /> 1 DISPOSAL PONDS ❑ <br /> -1 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 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 shalt not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature <br /> certifies the fotlnwin9: 111 certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspection . Complete drawing on re arse side. f �� <br /> Signed Title: C R <br /> Date: r CJ <br /> i FOR DEPART E O f Q• �2 6' <br /> Applicatio ccepted by <br /> Date -` vv Area <br /> jlZ Final Inspection by Date <br /> Pit or Grout Inspection by � Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 + <br /> Applicant - Return all copies to: Environmental Health.Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 55201 <br /> FEE AMOUNT DUE =REMITTED RECEIVED 13Y DATE PERMIT'ND.�INFO �EH13-24MEV:f/ns ��� <br /> EH 14-28 .. <br />