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s - <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> i (Complete in Triplicate) PA10 f d -7 �- <br /> al Health District for a permit to construct and/or install the work herein described.This application is <br /> Application is hereby made to the San Joaquin Loc <br /> e or No. 1862 for and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for sewagl <br /> Local Health District. ,f _ <br /> Jab Address CEN PM <br /> � Lot Size � p <br /> d Q\�..�--_ `-w Y-,0 Phone 5�—D8go <br /> Owner's Name �\1Address f r �� <br /> p L.✓Y� 4-LC� � Address�- m�"�"`'Jp f�Qicense No.#51°''V.-Phone <br /> Contractor r <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION L� SYSTEM REPAIR ❑ OTHER­-0171 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS--- .u. <br /> L] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private LJGravel Pack ❑ Tracy Type of Casing Specifications <br /> El Public ❑ Other ❑ Delta Depth of Grout Seal ,_Type of Grout <br /> L] — <br /> IrrigationApprox. Depth 13Eastern Surface Seal Installed by <br /> ` <br />` Repair Work Done El Type State Work Done Type of Pump <br /> Well Destruction ❑ Well Diameter Seating Material (top 501 y <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATI REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: R idence r` Commercial Other ti f1 <br /> Number of living units: Number of bedro ms % tl$ <br /> Character of soil to a depth of 3 feet: <br /> Water table depth <br /> f SEPTIC TANK ' Type/Mfg� � wei Capacity No. Compartments <br /> f PKG. TREATMENT PLT. ❑ ! q r � 1 r Method of Disposal <br /> f' Distance �Q <br /> !to nearest: Well i/Foundation Property Linemol <br /> ` LEACHING LINE LTJ No. & Length of lines r` Total length/size t <br /> FILTER BED ❑ Distance to nearest: Well_4W < Foundation� ! Property Line <br /> 1 i 1 <br /> f SEEPAGE PITS ElDepth Size Number ; <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> I DISPOSAL PONDS ❑ t " '" ." ".� .---r 1 <br /> ` I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an <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 in the performance of the work for which this permit is issued, I shat!hot,._ <br /> mpensation laws of California." Contractor's hiring or sub-contracting.signature <br /> employ any person in such manner as to become subject to workman's co <br /> certifies the f o g:"I certify that in the performance of the work for which this permit is issued,I shall employ persons 6bjecft"orkinan's compensa- <br /> tion laws of alifor 'a." <br /> The applican mu c II required inspections. Complete drawing on <br /> reverse side. r[ r <br /> Title:��ti<- {� Date'_ <br /> Signed <br /> ' FOR P�ARTMENT USE ONLY <br /> t <br /> A Z'i/ <br /> Application Accepted by Date'-"- `"`� Area v <br /> } <br /> Pit or Grout inspection by Date Final Inspection by ' <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6"385 _ <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.;CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE IPFRMITV'NO. <br /> INFO CASH <br /> + EH 13-241REV-tic5/ 'FSI � <br /> EH 1428 V O <br /> is <br />