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i <br /> APPLICATION FOR,PERMIT _ n <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT i !� L <br /> j 1601 E. HAZELTON AVE., STOCKTON, CA � '. "� �P RPSIT N0, <br /> Telephone (209) 466-6781 fh <br /> i <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ��� Z' 1987 ATE ISSUED <br /> i <br /> `(Complete in Triplicate) ENVIRQMENTAL <br /> Application is hereby made to the LSan Joaquin Local Health District for a permit �M s� @@�r�H�t@�@1 all the work herein <br /> �bP`ss <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 54 ge or No. 1862 for well/pump <br /> and the Rules and Regulations of the San Joaquin Local Health District., <br /> Job Address Subdivision- Name <br /> Owner's Name Address 10 ^ Phone <br /> Contractor's Name License No.. Z.1 Phone LVL-7 Z <br /> TYPE OF WELL/PUMP WORK:- NEYlWELL WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION I� SYSTEM REPAIR LL OTHER {J \ <br /> DISTANCE TO NEAREST: SEPTIC TANK !jf SEWER LINES f DISPOSAL FLD. _ PROP. LINE \. <br /> T <br /> OTHER WELL PITS/SUMPS <br /> FOUNDATION <br /> i AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PRO LEY AREA CONSTRUCTION SPECIFICATIONS I <br /> I``J��dustrial U Open Bottom nteca Dia. of Well Excavation <br /> XDOmestic/Private ravel Pack Tracy Dia. of Well Casing <br /> Public t er Delta Type of Casing (� <br /> k ❑ Irrigation l l{j Approx. Eastern Specifications 1 <br /> Cathodic Protection Depth <br /> Depth of Grout Seal <br /> Geophysical Type of Grout <br /> LJ Other Surface Seal Installed by Nt✓!J 'yy <br /> Repair Work Done G Type of Pump N.P. State Work Done <br /> Well Destruction U Well Diametertt Sealing Material (top 50') <br /> i Depth °E Filler Material (Below 501 <br /> if publTYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION J (No septic tank or seepage piavailableewithin 200cfeet.sewe) is <br /> i <br /> Other <br /> Installation will serve: Residence _ Commercial L <br /> Number of living units: Number of bedrooms Lot size <br /> Character of soil to a depth of[3 feet: Water table depth <br /> SEPTIC TANK E] Type/Mfg` Capacity No. Compartments <br /> '+ Capacity Method of Disposal <br /> PKG. TREATMENT PLT. Type/M% dtiop <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION 1 <br /> LEACHING LIKE U No. & Length of lines Total length/size <br /> FILTER BED EJ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth Size Number <br /> - SUMPS `bistanE'e'to nearest: Well Foundation — Property-L`ine'' <br /> DISPOSAL PONDS 0 <br /> i I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this <br /> permit is issued, I shall not employ any person in such manner as to become subject to workmank compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this permit is issued, I shall empl y ersons subject to workman's compensation laws of California." <br /> The applicant 1 for l `i red inspections. Complete drawi on r erse side. <br /> Signed X <br /> Title:- Date: <br /> R RTMENT USE ONLY 0Stk 466-6781 <br /> Application Accepted by E�. Area <br /> Additional Comments: [ Lodi 369-3621 <br /> Date Manteca 823-7104 <br /> Pit or Grout Inspection by �` <br /> > t Final Insp i " by 04 d 04 `` � t'k 5�r (A� <br /> Applicant - Retur` 1 copies to: . Environmental Health Permit/Services 160 E. Hazelton Ave., x 0 5tk�, CA 95201 <br /> E ���/111111��r <br /> FLFEEJBASE AMOUNT tOUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. <br /> —7c> , <br /> 10/82 500 <br /> EH 13-24 REV: 10/82 <br /> i 14-26 <br />