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APPLICATIONFOR PERMIT } F <br /> To,Com.,V--, P <br /> I SAN JOAO.UIN' LOCAL HEALTH DISTRICT ' <br /> .� <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> F Telephone {209).�-6781 <br /> Ddb t i�u�-T{.p`'_ ._.. <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> . , . <br /> (Complete in Triplicate) this r <br /> ation is <br /> all the <br /> rk <br />� <br /> Application is hereby made to the Sa6 Joaquin Local Health District for a permit N too construct8forwellldpump atnd the Rues and IR Regulations of he San r Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage <br /> Local Health District. a: <br /> City I `,-Lot Size PM <br /> Job Address 9 C13 oz <br /> ` f <br /> Address 0-W" C�7 Phone <br /> — <br /> I Owner's Name <br /> Phone <br /> License No. <br /> f Contractor's.Nartie WELL REPLACEMENT DESTRUCTION <br /> TYPE OF WELLIPUMP: NEW WELL ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ f' SYSTEM REPAIR ._ _ _ _ <br /> 1' SEWER LINES DISPOSAL FLD. PROP, LINE <br /> DISTANCE TO NEAREST:-SEPTiC'TANK' �—� PITS/SUMPS <br /> FOUNDATION <br /> AGRICULTURE WELL OTHER WELL <br /> �i <br /> INTENDED USE TYPE OF WELL <br /> PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> 1 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Industrial Type of Casing f�� Specifications <br /> Domestic/Private .Gravel Pack ❑ Tracy <br /> i ❑ Public f ❑ Other Delta Depth of Grout Seal : Typerof Grout <br /> fl Irrigation --Approx. Depth,,�fl Eastern Surface Seal Installed by i>� ri <br /> Type of Pump T� H.P. State Work Done ' - w <br /> Repair Work1D[ine yP - ;- _- <br /> I ` f Sealing Material (top 50'1 <br /> ! Well pestruct�on .« Well Diameter <br /> �. Filler Materia! (Below 50'1 <br /> Depth�.-" - <br /> I TYPE OF •EPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ available'within e200 feet.) if public sewer is <br /> lnstallati n ill serve: Residence— Commercial, Other <br /> Installatin s <br /> Number offying units: Number of bedrooms Water table depth f <br /> Character of soil to a depth of 3 feet: Capacity�.� No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal„' f <br /> PKG. TREATMENT PLT. ❑ Foundation <br /> Distance to nearest: Well Property Line <br /> Total length/size , <br /> LEACHING LINE ❑ No. & Length of lines ! <br /> Foundation '� Property Line <br /> FILTER•BED ❑ Distance to nearest: Weil w' <br /> Size <br /> i Number <br /> *SEEPAGE PITS ❑ Depth Foundation Property Line <br /> 1,SUMPS. ❑ Distance to nearest: Wellr l <br /> yDISPOSAL PONDS ED <br /> I hereby certifyahatl have prepared this application and'iharthe:work will`tie-`done in'accor'dance 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'iri•the>perfarmance of the work forwhich this permit is issued, l signature <br /> shall not <br /> r emplo s the personlowinn such ertify that n the performance of he wok fot to rwh ch thistpermit is issued,fI shall employ persons ornia.” Contractor's lsubject t workman's ring or sugcompensa <br /> certif g:" _ - u _ Y <br /> tion laws of'Califorhia."- <br /> The applica I for all require 'ns2/, <br /> ns. Ca ete drawing on reverse side. <br /> t_ p � <br /> Title: <br /> } ate <br /> Signed _ ' <br /> fie, +�-12�f S FOR DEPARTMENT USE ONLY <br /> Date x ) Area 1 a�� <br /> Application Accepted by �`"` 7-1 <br /> s Date �— Final Inspection by ` Date <br /> Pit or Grout Inspection by l <br /> Additional'Comments: ; <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83x6385 <br /> Ap licant r Return all copies to: Environ ental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,tCb 95201 <br /> l S $ 0�^ fio i old ti.r.� t vim" Gu . . <br /> CK RECEIVED BY DATE PERMIT'NO, <br /> FEE AMOUNT DUE AMOUNT REMITTED GASH <br /> INFO. <br /> fff111 :+EH 1324 IREV.161831 �7 <br /> EH 14-28 I <br />