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APPLICATION FOR PERMIT a <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE' TON AVE., STOCKTON, CA <br /> Telephone (209) 486-6781 rjl —Y J <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> j' (Complete in Triplicate) <br /> crib. <br /> . This <br /> C-1flon is <br /> all the <br /> rk <br /> n des <br /> Application is hes made <br /> Sanothe Joaqu n County ordinance lNth District for a o. 549 for sewage or permit <br /> No 1862 tar welldpumlp atnd the Roes and'R Regulations of he San Joaquin <br /> made in compliancel <br /> Local Health District. :' i =,,.��- 11' <br /> 9��- �� City .St-OC t'" 11 Lot Size PM <br /> Job Address <br /> �e fta V a fl ssd c;arty�� 9'a!© Carn,{d €�- � phone 9.$/- �f/L <br /> Owner's Name S S Address <br /> 1i �S /_ A.�e� D7�-Phone <br /> Contractor G y- <br /> r C Address �` � License No. <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑❑, <br /> PUMP INSTALLATION E7 SYSTEM REPAIR'D <br /> SEWER LINES D FLD• PROP. LINE <br /> DISTANCE TO.NEARES SEPTIC TANK �..--- PITS/SUMPS <br /> UNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TY OF WELL PROBLEM AREA STRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ Oen B orn ❑ Mantec <br /> Dia. Well Excavation r <br /> 1-1IndustrialP , Specifications <br /> ❑ cy Type of Casing <br /> El Domestic/Private ❑ Gravel Pack Depth of Grout Seal Type of Grout - <br /> f-I Public r Other Cl Delta <br /> A x. Depth Eastern. Surface Seal Installed by <br /> r I 1 Irrigation — - State Work Done_ <br /> Repair Work Done ❑ e of PumpH.P- <br /> Well Destruction Well Diameter eating Material (top 50'1 <br /> { Depth Fit Material {Below 501 <br /> k TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/A (TION l 1 :DEST UGT10N 1 available1w thin 200 feetseptic system .) if ppublic sewer is <br /> i <br /> Installation will serve: Residence Commercial_ Other t <br /> 1. . t F <br /> ! Number of living units: Number of bedrooms �.1. <br /> Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Pro err Line <br /> Distance to nearest: Well Foundation P Y <br /> LEACHING LINE ❑ No. &F�ength of lines- <br /> Total length/size <br /> ❑ Distance to nearest: Wel Foundation Property Line <br /> FICTER BEP 1 <br /> l l Depth I Size Number <br /> SEEPAGE PITS <br /> SUMPS ❑ Distance to nearest: Well-. Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 Di1trict. t <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 shall not <br /> signature <br /> employ any person in such manner as to become subject to workman's compensation laws of California.'" Contractor's nstsub ect to workman'sring or tcompensa <br /> certifies the following: "I certify that in the performance of-the�k for which this permit is issued,I shall employ p 1 <br /> tion laws of California." <br /> The applicant ust call for all required inspect ns. Co> is drawingix�� <br /> O <br /> {i/(�J YJ . Date: <br /> Signed X r Title: <br /> FOR DEPARTMENT USE ONLY _ �°� <br /> Date _ Area (-J <br /> Application Accepted by J{,� <br /> Final Inspection by Date <br /> .Pit or Grout inspection <br /> Date L I <br /> Additional Comments: <br /> ❑ Stk 466.6781 OL odi 369-3621 ❑ Manteca 823-7104 0-Tracy 838-6385 <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 ND. <br /> FEE <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO << <br /> aEH 13-24.{REV.t/n <br /> EH 14-26 <br />