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APPLICATION FOR PERMIT <br /> J <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601E. HAZEL i ON AVE., STOCKTON, CA <br /> Telephone'(209) 466-6781 <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete.in Triplicate)ct and/or I install the work here-in described.This ap,.piication is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to constru well/pump and the Rules and Regulations of the shn Joaquin <br /> with son Joaquin county ordinance-No.549 for sewage or No. 1862 for <br /> made in compliance <br /> Local health District.'. <br /> Lot Size P <br /> Xe "cit, 5,6)ck . <br /> Job Address <br /> o5l 5owt4 <br /> ILI - rvest— I'lepho, A0 $410. <br /> Address <br /> -Owner's- N 0 <br /> ame <br /> 92 L 37C 41 Phone 0 <br /> P.O.&Y a q( _1�icense No. 3- 6 f 6, v <br /> Contractor Address WELLREPLACEMENT0 DESTRUCTION 0 <br /> TYPE OF WELL/PUMP: N WELL SYSTEM REPAIR El OTHER <br /> PUMP INSTALLATION FLD.— PROP. LINE <br /> ;� <br /> DISTANCE To NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL _ OTHER WELL A <br /> TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE 0 Open Bott , 0 Manteca Dia. of Well Excavation Di,, of Well casing <br /> 0 industrial Bottom Type of Casing > specifications &-V4%4 <br /> C] Gravel Pack [I Tracy I <br /> 7 Domestic/Private El Other 0 Delta Depth'of Grout Type of Grout <br /> Ll Public ---Approx..Depth 0 Eastern Surface Seal Installed by <br /> [_1 Irrigation 7i State Work Done <br /> Repair Work Done [I Type of Pump H.P. 7 <br /> ieter Sealing Material (top 501 <br /> Well Destruction El Well Diary <br /> Depth Filler Material(Below 501 yst <br /> •"'W %I ern permitted if public dower is <br /> INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION 0 (No septic s <br /> TYPE OF SEPTIL; Vyumv,: NEW septics 200 feet.) <br /> installation will serve: Residence rte <br /> Commercial— Other <br /> Number of living-units:_ Number of bedrooms .1 <br /> I :. –Water table depth <br /> Character of soil to a depth of 3 f'eet: Capacity <br /> No. Compartments <br /> SEPTIC TANK E Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ED t I <br /> Distance to nearest: Foundation Property Line <br /> Total-length/size <br /> LEACHING LINE 0 No. &'Leniith of lines <br /> Property Line <br /> FILTER BED El Distance to nearest: Well Foundation <br /> Number---------- <br /> SEEPAGE PITS C Depth-- Size <br /> Foundation Property Line <br /> SUMPS C3 Distance to nearest: Well <br /> DISPOSAL PONDS ❑ accordance with an Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and that the work will be done in <br /> rules and regulations of the San Joaquin Local Health District. I <br /> Horne owner or licensed agent's signature certifies the following: ', certify that in the performance of the work for which this permit is issued, I shall not <br /> act to workman's compensation laws of California." Contractor's hiring or sub-contnilcting signature <br /> employ any person in such manner as to become subi compensa- <br /> t in the performance of the work for which this Permit is issued,I shall employ persons subject to workm�n's <br /> certifies the f ollovding: ­I certify the <br /> tion laws of California." <br /> The applicant t call f quire ctions. complete drawing on re rse 'd <br /> 7, _T Date: old <br /> Signed Title. — 5 <br /> R DEPARTMENT USE ONLY <br /> DEPARTMENT <br /> D 11A Area <br /> � ap <br /> Application Accepted b <br /> .to <br /> t"�by ate <br /> 's�I <br /> ns ton <br /> Pit or Grout Inspection y at <br /> Additional Comments: -7104 0 Tracy 835-6385 <br /> 0 Stk 466-6781 _ 0 Lodi .369-3621 . 0 Manteca 823 P.O. Box 2009, Stk., CA 95201 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., <br /> N6. <br /> EEO JER;ECEIVED�161Y DATE PERMIT'NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO 10_7 <br /> -00 <br /> %a EH 13-24 1 REV.1/95) <br /> EH 14-26 <br />