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� a <br /> • APPLICATION FOR,PERMIT t, <br /> ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELT0N AVE., STOCKTON, CA <br /> _ — Telephone {209) 466 6781 <br /> PERMIT EXPIRESA1 YEAR FROM DATE ISSUED <br /> 59` i c xv a <br /> a � ��; � � : _ .� s=�i�I`3 y�;;.�{Complete yin Triplicate/.�h:�� �Y� "r�s1: ,. o Itis <br /> Application is he made to the San Joaquin Local Health District for a permit to construct and/or instals the work hereindescribed. This application is <br /> made in compliance with-San Joaquin County,Ordinance:No 549;for sewage-or No.1862 forwell 1pump-and the Rules and Regulations of the San Joaquin <br /> Local Health District,,,/ a i j �l?:,..Tri r <br /> .. /��,Q (f' ��;i[ 14'rt" k,' E .r�.F'�r ?3 "Sf i.:Si. <br /> .#,..,alp f c�. ?-.x� � <br /> /�/"4 .4 r-16 flee �l'. 16S- <br /> Job <br /> i AddressPM <br /> _ v <br /> city � ►rin'.L S <br /> ,,t <br /> size <br /> Owner s Name a Address _. � Phone / <br /> �y77V01 t1622 4 <br /> I Contractor's Name License No. Phone <br /> Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ ter' WELL REPLACEMENT ❑�.f —DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC.TANK SEWER LINES - _ DISPOSAL FLD.` PROP.:LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE,OF WELL PROBLEM AREA s'CONSTRUCTION SPECIFICATIONS <br /> ❑ Indusfrial ___--'-'[],Open Bbttom ❑-Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 13 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ElPublicY ❑'Other i ❑ Delta s rDepth of Grout Seal ' Type of Grout <br /> Q irrigation --!.Approx. Depth ❑ Eastern Surface Seal Installed by ,1 <br /> Repair Work Done ❑ Type of:Pump� H.P. State Work Done_ \J <br /> Well Destruction ❑ Well Diameter Sealing Materia! (tap 50') �- <br /> r-'' Depth - iller Material'(Below 501 <br /> t <br /> ! . <br /> :TYPE OF,SEPTIC WORK:.—NEW INSTALLATION_ -• E.PAIR/ DITION ❑ `DESTRUCTION ❑ (No septics <br /> system permitted if public sewer is <br /> y . available within 200 feet.) <br /> Installation-will_serve:: Residehcer=.-Commercial- Other ­Z, t`. r _ <br /> F Number of living units: Number of be ms5'1j <br /> r Character of soil to a depth-of 3 feet: Water table depth r <br /> SEPTIC TANK t li_ Type/Mfg ' CapacityIZ.__ No. Compartments . r <br /> PKG. TREATMENT1PLT. ❑ f Method of Disposal } ' <br /> �• <br /> Distance to nearest: Well l/7/ Foundation �� Property Line IJP <br /> LEACHING LINE No. & Length-of lines — `T D Total length/size <br /> FILTER BED ❑ 4Distance to nearest:« Well -Foundation Property tine <br /> A I <br /> 'SEEPAGE PITS ILS Depth Size Number <br /> SUMPS' i ElDistance to nearest: -Well' 0" ' Foundation�__ Property Line <br /> —DISPOSAL PONDS:.. . . ❑. - <br /> hereby certify that I have prepared this application and that the,work swill be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San,-Joaquirf-L-oca(,,Health <br /> Norrie owner or licensed agent's signature certifies the following: , <br /> 9 g g:"I certify that in the performance of the work for which this permit is issued, {shall not <br /> -*employ any person in-such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature <br /> Ccertifses the following: "I certify that in the performance of the work for which this permit is issued,'l shelf employ persons subject to workman's compensa- <br /> tion laws sof California' _47 - <br /> The applicant c II for all required i Ctions.r Complete drawing-on-reverse side. <br /> :Signed Title Date: <br /> FOR DEPARTMENT USE ONLY f r { <br /> Application Accepted by Date Z Area LI T <br /> Pit or Grout Inspection'by ! 0 Date Final Inspection by Date l <br /> Aoditional Comments: <br /> tk 466 6781 ❑ Lodi 369 3621 ❑ Manteca 823-7104 - ❑ Tracy 835-6385 +Applicant- Return all copies to:-Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,'Stk., CA 95201 <br /> r n INFO rAMOUNT DUE } `� AMOUNT REMITTED C A9RRECEIVED BY DATE` PERMIT"N0. <br /> yANt EK 13.24(REV.101133) ; <br /> EM 14-26. ». -... <br />