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T APPLICATION FOR PERMIT <br /> L SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED'_ " <br /> {Complete in Triplicate} +� <br /> J, Ths <br /> appl <br /> cation is <br /> Application is hereby made to the San�oui OrdinaLocalnce No.649 for sewage r INo. 1862 forcwell//pump and the Rules and(Regulations of he San Joaquin <br /> un <br /> made in compliance with San Joaquin tY �,. . .�w.t <br /> t Local Health District. Cly � �.4....\" .. r <br /> � t Lot Size f A C- ' PM <br /> Job Addre� 40 •�!os lfJ/GSdA � <br /> �a�JCx� - Address � G G 65 Phone <br /> Owner's Name ,_. <br /> _ 'hon, <br /> Contractor (= Z) E' wit, Address tve�rlll.. L!_ "AA) —License No.4`Yi Y7d <br /> TYPE OF WELL/PUMP. NEW WELL 1:1WELL"REPLACEMENT`❑—"�? DESTRUCTION-O' <br />' PUMP'INSTALLATION 11SYSTEM REPAIR E3OTHER .0 <br /> D15TANCE TO NEAREST: SEPTIC TANK SEWER LINES �" DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICUt:TURE' L'L1__ OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑—Manteca Dia.'of Well Excavation <br /> Dia. of Well Casing W <br /> ❑ Tracy Type of Casing °". Specifications <br /> Ll Domestic/Private ❑ Gravel Pack x _ T e of Grout <br /> I] Public [D Other ❑ Delta �'" Depth_of.Grout Seal_yP <br /> ❑ Irrigation. ---Approx. Depth Ll Eastern Surface Seal Installed by <br /> H.P. State Work Done <br /> Repair Work Done ED Type of Pump <br /> tSealin Material (top 50'1 <br /> Well Destruction' E3 Well Diameter g _. <br /> Depth Filler Material jBelow 501 - <br /> GIN <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION C] REPAIR/ADDITION <br /> DESTRUCTION Elalvailablpelwithine200 feett�ed if public sewer is <br /> t Installation will serve: Residence Commercial_ Other <br /> Number of living units: '1/ Number of bedrooms. Z <br /> Water table depth <br /> ` Character of soil to a depth of 3 feet: L No, Compartments <br /> SEPTIC TANK ElTypelMfg Capacity <br /> f Method of Disposal <br /> PKG. TREATMENT PLT. ❑ s <br /> Distance to nearest: Well Foundation Property Line <br /> r <br /> Total length/size X `� <br /> LEACHING LINE No. & Length of lines /, �Q — ZO i <br /> i FILTER BED ❑ Distance to nearest: <br /> / Well M19 F" Foundation Y� Property Line (' <br /> � , <br /> SEEPAGE PITS LAS Depth y�� Size 3� Number <br /> SUMPS ❑ Distance to nearest: Well Ig1A7t Foundation Property Line �� Z <br /> DISPOSAL PONDS. ❑ <br /> 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 /> following: "I certify that in the performance of the work for which this permit is issued, <br /> Home owner or licensed agent's signature certifies the 1 shall not <br /> employ any person in such manner 5s'-to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify that iri 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 fora required inspec' ns. Complete drawing on.leve se side. <br /> Date: <br /> Signed <br /> 'FOR 15EPARTM T USE ONLY �j <br /> �* Date "�r Area <br /> Application Accepted by <br /> /pL`4/ 4 Date�� <br /> Pit or G ouL Inspection by r Date !Or Finale Inspection by d <br /> Additional Comments: _ <br /> ❑ Stk 466-6781 / _❑ Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE CK RECEIVED BY DATE ENO.'INFOAMOUNT DUE AMOUNT REMITTED CASH+ EH.13-24(REV.7 �� ` <br /> S. a <br /> EH 1428 <br />