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z <br /> f <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone 1209? 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ' (Complete in'Triplicate) <br /> /or install the work herein <br /> This application is <br /> Application is hereby made to the San Local Nth District for a o. 549 for sewage or INo t to 1862 forcwelltlpump and the Rules and fl gulations o4 the San Joaquin <br /> made in compliance with San Joaquin ty Ordinance <br /> Local Health District. I. <br /> `City Lot Size PM <br /> Job Address % <br /> r <br /> �I,� 97 Phone <br /> `�T` l�c.�r: J�5' <br /> Owner's Name _ Address <br /> _ e License No% Phone 3 <br /> i <br /> Contractor "L`� Address <br /> WELL REPLACEMENT- DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: _ NEW WELL L3� OTHER L)PUMP INSTALLATION C*�'`• SYSTEM REPAIR L] <br /> DISTANCE TO NEAREST: SEPTIC TANK - — SEWER LINES 7S/ , PROP. LINE <br /> DISPOSAL FLO <br /> s l�dz AGRICULTURE WELL -260 r OTHER WELL /.0j PITS/SUMPS <br /> FOUNDATION <br /> INTENDED USE TYPE OF�WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavatio <br /> a Domestic!Private "' u`���;Gravel"Pack ❑-Trac`y "�'-TV—56--o'Casing - <br /> Specifications <br /> ❑ Delta Depth of Grout Seal - Type of Grout <br /> FI Public ❑ Other s <br /> I ( Irrigation - App uo Qepth Eastern Surface Seal Ins <br /> f Putalled by <br /> Repair Work Done 11 Type o 1 p <br /> H p _ State Work Done .� <br /> Well Destruction ❑ Weil Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I') REPAIR/ADDITION l 1 DESTRUCTION I 1 eNOklabPelwit in 200 1eetsysm �1]ed iF public sewer is <br /> --installation will serve: Residence Commercial� Other' <br /> Number of living units: Number of bedroomsi 4- -- Water table depth <br /> Character of soil to a depth of 3 feet: <br /> '' - � � Capacity No. Compartments <br /> SEPTIC TANK ❑ TypelM4g �_.j _ <br /> . �-, `• Method of Disposal <br /> -PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well 1 Foundation PropertyLine <br /> LEACHING LINE ❑ No. & Length of lines }. '* Tota! length/size <br /> E] Distance to nearest: Well Foundation Property Line ` <br /> FILTER BED <br /> I 'Sie J Number <br /> SEEPAGE PITS 11 Depth zz <br /> y SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 4 1 <br /> i <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, an <br /> rules and regulations of the San Joaquin Local Health District. ' <br /> rtify 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 the following: "I ce <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractto�nsir g or b'ect to workman'sgompature <br /> certifies the following:"1 certify that in the performance of the work for which this permit is issued, I shall employ p 1 <br /> tion laws of California." !4 r { <br /> R <br /> The applicant mu II far It required i pectionsC`-- plete-drawing o verse'sida' <br /> j e: Date: <br /> Signed <br /> FOR DEPARTMENT USE ONLY <br /> j ,y U Date-_ - `- - Area <br /> t Application Accepted CAO <br /> b ' <br /> TT Date Final Inspection by Date <br /> Pit or Grout inspection.by <br /> 1 �. <br /> Additional Comments: <br /> ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 Tracy 835- <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201. <br /> CK .RECEIVED BY DATE PERMIT'NO. <br /> (NFD AMOUNT DUE AMOUNT REMITTED CASH <br /> �. �— �{� <br /> t. +.EH 13-24(REV. i K 51 , r) .- • ��� �r��- / L� <br /> - EH 14-28- ���....++++++++ .� <br />